The Role of a School Nurse During Medical Emergencies

About

➀ Read and Learn

The following course content

Introduction to Medical Emergencies During School

As a school nurse, you oversee hundreds, possibly thousands of students. You are typically the only trained healthcare provider in the building saddled with the responsibility of triaging, medicating, treating, assessing, and discharging students from your office. Performing the role of caregiver for such a large population can seem like an impossible and overwhelming responsibility.  

A national survey was conducted of 573 school nurses (1) to determine the number of 911 calls placed from K-12 school campuses. It was determined that 68% of all 911 calls placed by schools in one year were related to life-threatening emergencies. It was further determined that injuries accounted for two-thirds of all EMS activation to schools, the remaining one-third being medical emergencies (1).  

The need to recognize and understand what actions must be taken during medical emergencies in schools is vital for every school nurse. Quick actions, followed by confident treatment can be the difference between life and death for a student. The aim of this course is to provide you with the knowledge of what medical emergencies look like in schools and what your role is during those emergencies.  

Allergic Reactions 

Either at the beginning of the school year or when the student is first enrolled, the guardians should fill out a health form. This form should include questions about the student’s health along with any pertinent information necessary for the school nurse to know. One of these questions should be related to any allergies the student may have. The guardians should explain the type of allergy or allergies the student has and what they do at home when the student begins to have an allergic reaction. This information will help the nurse create an individualized health care plan for the student should any medical emergencies occur.  

Symptoms of Mild and Moderate Allergic Reactions (2):

• Runny nose
 
• Itchy/watery eyes
 
• Itchy throat
 
• Coughing/wheezing 
 
• Rashes/hives
 
• Tissue swelling 
 

If a student presents with mild to moderate reactions, monitor the student for further signs of severe reactions. Inquire with the student if they touched/ate something that could have caused the reaction. If the answer is yes, remove that allergen if possible. If a student begins to demonstrate signs of an itchy throat, coughing/wheezing, rashes/hives, or tissue swelling, administer emergency Benadryl and contact the student’s guardians.  

Symptoms of Severe Allergic Reactions (Anaphylaxis) (2):

• Swelling of face, lips, tongue, mouth or airway
 
• Wheezing/shortness of breath
 
• Tightness in chest
 
• Dizziness
 
• Blue/gray discoloration around lips
 
• Nausea/vomiting
 
• Itchy skin/hives/other rashes that appear quickly
 

Students with a known history of severe allergic reactions should be seen and treated immediately to prevent further injury or death. If a student presents to the nurse’s office in anaphylaxis: administer epinephrine, call 911, and then the student’s guardians. The nurse should also call for help from another adult in the building. This will allow the nurse to focus on the student, while the other adult present can place the 911 call and calls to the student’s guardians. It is also important to have an additional adult present in the event that the student becomes unresponsive. This will allow for 2-person, high-quality CPR.  

Asthma Attack 

Asthma is the number one cause of chronic disease-related absenteeism in schools (4). Children are prone to asthma attacks due to narrow airways and increased inhalation when compared to adults (5). Studies have estimated that 8.4% of children in the United States are diagnosed with asthma (10). Although it is treatable, undetected asthma attacks can quickly become severe medical emergencies.

Like allergies, the student’s guardians should have indicated on the student’s health form if the child has been diagnosed with asthma. If the student has been diagnosed with asthma, the family should provide the school nurse with a rescue inhaler and a note from the student’s doctor indicating when the inhaler should be utilized.  

Early Signs of an Asthma Attack (2):

• Coughing
 
• Shortness of breath while walking
 
• Tickle in throat
 

Moderate to Severe Symptoms of an Asthma Attack (2):

• Tightness in chest
 
• Wheezing/grunting
 
• Unable to speak in complete sentences, or at all, without stopping to breathe
 
• Gasping/rapid breathing
 
• Nostril flaring
 
• Feelings of fear or confusion
 
• Blue/gray discoloration to lips or skin
 
• Changes in mental status 
 

For any student presenting with signs of asthma, check the student’s oxygen level and listen to their lung sounds. If the student’s oxygen saturation is below 92%, call 911. An oxygen saturation lower than 92% indicates that the student needs oxygen. While listening to lung sounds, be alert of wheezing or diminished breath sounds; these indicate the need for an inhaler. If you have given the student their rescue inhaler, but they do not show signs of improvement in their overall symptoms within 20 minutes of inhaler administration, call 911 and the student’s guardians.  

Choking 

Staff should be educated on how to perform the Heimlich maneuver in the event of student choking, as it is one of the most common medical emergencies in schools. If a student begins choking while at school and the student is not in the nurse’s office, the staff member with that student should begin attempting to clear the their airway. The staff member should also send another student or adult to get the nurse.

Clearing a Blocked Airway for Older Students (2):

1. Get behind the student, make a fist with one hand and grasp the fist with the other hand.
 
2. Position fisted hand slightly above the student’s navel, pull the student close to you, then give a hard thrust with your fist in an upward motion against the student’s abdomen.
 
3. Continue hard thrusts into the student’s abdomen until the object becomes dislodged or the student becomes unresponsive.  
 
4. If a student becomes unresponsive, begin high-quality CPR, have someone call 911, and the student’s family
.
5. Continue CPR until the student becomes responsive or until EMS arrives and takes over.
 

If the object was dislodged and the student remained responsive, bring the student to the nurse’s office to monitor the student for signs of distress. Ensure that the student’s family has been called and updated on the situation. Inform the guardians that the student should be seen by their healthcare provider.  

Severe Bleeding 

Severe bleeding in a school setting can come from many different environments: playground accidents, altercations with other students, equipment failure, or nosebleeds. Unlike most medical emergencies, all severe bleeding requires the same steps to be taken in order to slow, stop, and treat the bleeding.

First Aid for Severe Bleeding (2):

• Have the student lie down
. 
• Apply direct pressure to the wound for at least 5 minutes in order to slow the bleeding. If blood seeps through, apply more dressings (do not remove old dressings). 
• If you notice an object protruding from the student’s skin, do not remove it.  
 
• Monitor the student for symptoms of shock due to blood loss. These will include: pale or cold skin, confusion, rapid heart rate, rapid/shallow breathing and weakness.
 
• If you are unable to stop the bleeding after 5-10 minutes of pressure, call 911 and the student’s guardians. 
 

Back and Neck Injuries 

Back and neck injuries typically occur after a student falls. They can also occur during a sporting event if the student collides with another student or outside of the school setting at home. Simple back and neck pain can be remedied by a hot pack and an NSAID, if the student’s guardians have given the nurse permission to administer medication to their student. 

If the student experiences serious back pain (i.e. they fell from the monkey bars and landed on their back), ensure that the student is not moved, remains still, and that their neck is immobilized as well by gently holding their head. While keeping the student immobilized, call 911 and the student’s family. 

Signs to Watch for in the Student (2):

• Inability to move arms or legs
 
• Tenderness, swelling, or bruising to back or neck
 
• Headache, or pain radiating through shoulders
 
• Desire to keep their neck still
 

Broken Bones 

Broken bones are one of the most common medical emergencies in a school setting. Primarily, broken bones will occur at recess or during the student’s gym time. Depending on your school’s policy, not all students suffering from broken bones need to be transported to the hospital by EMS. However, all compound fractures will need to be transported to the hospital via EMS.  

Steps for Compound Fractures (2, 3):

• Control the bleeding by applying pressure to the site of injury
 
• Do not move the affected limb unless the student must be moved, then splint the limb with a folded blanket, magazine, or piece of cardboard
 
• Watch for signs of vascular injury:
 
• Lack of pulse
 
• Continued blood loss
 
• Expanding hematoma 
 

It is possible a student will present to your office with what appears to be a sprain but is a fracture. Since you will not be able to assess fracture vs. sprain, you can complete the following steps (2): 

1. Rest: allow the student to find a comfortable position to rest in.
 
2. Ice: provide ice to injured extremity. Do not allow the student to use ice for more than 30 minutes
.
   
3. Elevation: if swelling is noted, elevate the affected extremity above the level of the heart
.
   
4. Call the student’s guardians and explain the injury. 
 

Burns 

Burns are not as common in a school setting but should still be reviewed in the event it should occur, as it can be one of the more extreme medical emergencies. Burns are categorized into three degrees: first (superficial), second (partial thickness), and third (full-thickness). A first-degree burn involves the top layer of skin. A second-degree burn involves several layers of skin and can cause blisters. A third-degree burn involves damage to the full depth of skin as well as muscles and nerves.  

For any degree of burn, the first course of action is to cool the burn. This is accomplished by placing the burn in cool water. If the burn is in an area that is not easily accessible, place a cool, wet cloth on the area. Do not fully submerge a student in cool water in order to avoid dropping the student’s core temperature too low (2). 

Two types of burns a nurse may encounter in the school setting are chemical and electrical. For both types, ensure the area is safe before attempting to remove the student from the area. Burns involving the face, genitals, eyes, hands or feet should be assessed at the closest hospital via EMS transportation. EMS should also be called if the burn is larger than 1% of the student’s body surface (or the size of the student’s palm) (2). 

Chemical Burn First Aid (2):

• If in eyes – immediately rinse chemical from eyes
.
  
• If the chemical is dry – brush off the skin, then rinse under water for 15-20 minutes.
 
• If the chemical is wet – wash the affected area for 20 minutes
.
  

Electrical Burn First Aid (2):

• Power MUST BE shut off before attempting to rescue the student. If a power line is down, you must wait for the fire department or power company
.
  
• All electrical burns should be assessed at the nearest hospital.
 

Diabetes 

Diabetes is a chronic condition where a person’s blood glucose (blood sugar) is too high. Diabetes is the second most common chronic condition in children, with type 1 diabetes being more prevalent than type 2 diabetes (9). With type 1 diabetes, the body does not produce insulin, so the glucose cannot effectively enter cells. This causes individuals with type 1 diabetes to have abnormally high sugar levels, resulting in them taking insulin every day, multiple times a day (8).  

The onset of type 1 diabetes is difficult to diagnose. The student will typically present with several weeks’ worth of increasing fatigue or intermittent polydipsia and polyuria, and any recent illness or travel can exacerbate the symptoms (9). If diabetes is not recognized during this early stage of presentation, the student is likely to go into a hyperglycemic crisis that ultimately requires treatment and possible admission to a hospital; in short, diabetic emergencies are medical emergencies that need immediate treatment.

A child who is diagnosed with type 1 diabetes will require several interventions in a school setting. There are three types of health care plans that should be the guiding factor for the student’s diabetes management: Diabetes Medical Management Plan (DMMP), Individualized Health Care Plan (IHP), and Emergency Care Plans for Hypoglycemia and Hyperglycemia (8). 

Diabetes Medical Management Plan (8)

• Completed by the student’s health care team
.
  
• Contains medical orders that outline the student’s health care and education plans.
 
• When to review/change the DMMP
.
• Start of each school year
.
  
• After a change in the student’s prescribed plan of care
.
  
• Upon request by the guardians or physician
.

Individualized Health Care Plan (8)

• This plan is prepared by the school nurse.
 
• Lists out strategies for carrying out the student’s DMMP while at school
.
  
• A nurse prepares the IHP based on the student’s medical orders in the DMMP and then reviews the IHP with the student’s guardians.
  

Emergency Care Plans for Hypo/Hyperglycemia (8)

• Must be based on the student’s DMMP.
 
• Plans provide details on how to recognize and treat hypoglycemia and hyperglycemia, as well as who to contact for help
.
  
• School nurse in charge of developing these plans.
 
• Plans will be reviewed with the student’s guardians and copies of the plan will be provided to the student’s guardians, all school personnel in charge of a student during the day and during school-sponsored activities
.
  

A school nurse and/or school personnel must recognize the signs of a hypoglycemic and hyperglycemic emergency. Hypoglycemia is defined as blood sugar below 70mg/dl, whereas hyperglycemia is defined as a blood sugar above 240mg/dl (2). 

Hypoglycemia (2) 

Symptoms
:

• Irritability
 
• Shakiness
 
• Excessive sweating
 
• Paleness
 
• Weakness
 
• Lethargy
 
• Fatigue
 
• Confusion 
 
• Trembling
 
• Slurred speech
 
• Blurred vision
 

First Aid for Mild to Moderate Low Blood Sugar
:

• Follow the student’s IHP.
 
• Have student consume 15 grams of a quick-acting carbohydrate (i.e. 4 oz of juice, 3 tsp of glucose gel, 3-4 glucose tabs).
 
• Wait and monitor student for 15 minutes.
 
• The nurse or student will recheck the student’s blood glucose, if blood glucose is still below 70mg/dl, have the student consume another 15 grams of a quick-acting carbohydrate.
 
• Wait and monitor the student for another 15 minutes.
 
• If a student’s blood sugar is above 70mg/dl, and the student’s next meal is more than 30 minutes away, have the student consume a protein/complex carbohydrate snack (i.e. cheese and crackers
).
  
• If the student’s blood sugar is below 70mg/dl, follow the student’s emergency instructions on the IHP.
 

First Aid for Severe Low Blood Sugar:

• If the student’s blood sugar is severely low, they may be unable to swallow, they may be unconscious, or they may have a seizure.
 
• It is important to not give the student anything orally.
 
• Call EMS and student’s guardians.
 
• If there is a healthcare provider order, give Glucagon
.
  
• If the student becomes unresponsive, be prepared to perform CPR.
 

Hyperglycemia (2) 

Symptoms:

• Extreme thirst
 
• Rapid breathing
 
• Frequent urination
 
• Warm, dry skin
 
• Drowsiness
 
• Nausea/vomiting
 
• Headache
 
• Fruity smell on breath
 
• Loss of responsiveness 
 

First Aid:

• Follow the student’s IHP.
 
• Have the student consume water or a sugar-free liquid
.
  
• If stated in student’s IHP, have student dose themselves with insulin.
 
• Check the student’s urine for ketones
.
  
• If the student becomes unresponsive, call EMS, the student’s guardians and be prepared to perform CPR.
 

Concussion 

Concussions are described as a type of traumatic brain injury resulting from a blow to the head, or a hit to the body that causes the brain to rapidly move in a back and forth motion inside the skull (11). Although they may not always be extreme, in some cases, they can present as one of the most dangerous medical emergencies in a school setting. When attending to a child with a head injury and/or concussion, ensure that you do not move them unless absolutely necessary.

Signs of a Concussion (2)

Symptoms
:

• Unresponsiveness for any length of time
 
• Confusion and/or memory loss
 
• Sleepiness
 
• Listless
 
• Agitation/irritability/combativeness
 
• Pale or sweaty skin
 
• Nausea and/or vomiting
 
• Severe headache or dizziness
 
• Blurred vision
 
• Trouble walking or balance
 
• Slurred speech
 
• Seizure
 
• Blood or clear fluid dripping from the nostril or ear canal
 
• Clear fluid typically indicates cerebral spinal fluid
 
• Loss of bowel or bladder function 

First Aid:
 

• If vomiting after a head injury, immediately call EMS and the student’s guardians.
 
• Watch student for signs of a concussion
.
  
• Give the student an ice pack to place on  the site of injury in order to reduce swelling.
 
• If a concussion is suspected, do not allow the student to continue to play sports or any sort of physical activity.
 
• Contact student’s guardians and advise them to consult with the student’s healthcare provider.
 

Loss of Consciousness  

Fainting or loss of consciousness is typically brief, lasting no longer than a minute. There can be several causes for fainting ranging from lack of food or water to diabetes and low blood sugar. However, fainting is generally treated the same way, no matter the cause. It is important to note that any loss of consciousness is still considered one of the many medical emergencies that can happen in a school setting.

First Aid (2):

• Lay the student on their back and assess their breathing.
 
• If the student is not breathing, begin CPR. Have someone contact EMS and the student’s guardians.
 
• If the student is breathing, prop their legs up to increase blood flow to the brain.
 
• Loosen any tight clothing the student may have on
.
  
• Do not administer anything orally.
 
• Inform the student’s guardians of the incident and advise them to consult with their healthcare provider.
 

Jaw Injury 

A jaw injury can occur in any situation; however, it will mainly occur when the student is physically active (at recess, during gym time, or while participating in a sporting event). Due to the potential for breathing problems, school nurses must consider broken or dislocated jaws as medical emergencies, and EMS must be called. 

Symptoms (2):

• Bleeding from the mouth
 
• Difficulty opening the mouth widely
 
• Facial bruising or swelling
 
• Jaw stiffness, tenderness, or pain
 
• Loose or damaged teeth
 
• Lump or abnormal appearance on the cheek or jaw
 
• Numbness to the face, mainly the upper lip
 
• Very limited movement of the jaw (seen with severe fractures)
 

First Aid (2):

• Apply a temporary bandage to the jaw by wrapping gauze around the top of the head and under the jaw. This will prevent movement of the jaw
.
  
• Ensure the student’s guardians are away that they are being transported to a medical facility. 
 

Seizures 

Epilepsy is a common brain disorder that is most likely seen in children and older adults. It is estimated that around 470,000 children are diagnosed with epilepsy (12). Around 5-10% of childhood epilepsies fall under the category of absence epilepsy which presents as situational apathy (6). Childhood epilepsies are typically controlled by daily medications; however, epileptic episodes are considered medical emergencies that school nurses must be aware of.

There are several actions school nurses can do to help regulate a student’s epilepsy. One of those actions is to initiate a Seizure Action Plan. This action plan details what the student’s epilepsy looks like, first-aid measures, and when the student is to receive their rescue seizure medication. This plan is to be discussed with the student’s guardians to ensure its accuracy. Once the plan is approved, it should be distributed to the student’s teacher(s) and explained. Allow the teacher(s) to ask questions regarding the plan and ensure they are comfortable with their role. 

Convulsive Seizure (2)

First Aid:
 

• Follow students IHP and Seizure Action Plan.
 
• Move toys and furniture out of the way, so the student does not get injured.
 
• Protect student’s head with a towel, blanket, or clothing.
 
• Monitor how long the seizure lasts and what the student’s body looks like while they are having a seizure:
 
  • Eyes blinking, rolling up, staring off

    
  • Lip-smacking
 
  • Head movement
 
  • Vocalizations  
 
  • Legs stiff or kicking
 
  • Arms in a locked position or jerking
 
• Have student rest on their side once the seizure subsides
.
  
• Stay calm and try to offer privacy.
 
• Do not restrain the student or put anything into the student’s mouth during a seizure
.
  
• Inform the student’s guardians after the seizure.
 

When to Call 911:
 

• If the seizure lasts longer than three to five minutes
 
• If the student has difficulty breathing
 
• If the student is seriously injured
 
• If the student does not have a history of seizures
 

Nonconvulsive Seizure (2) 

First Aid:
 

• Monitor how long the seizure lasts.
 
• Stay with student and reassure them.
 
• Let the student rest
.
  
• Follow the students IHP and Seizure Action Plan.
 
• Inform the student’s guardians after the seizure
.
  

What to Look for in a Nonconvulsive Seizure:
 

• Blank look on student’s face
 
• Student unable to speak or move
 
• Student acting in odd or strange ways
 
• Students chewing or smacking lips
 
• Student toying with their clothing
 

CPR/AED 

If a student is in need of CPR, it is considered one of the many medical emergencies that can occur within a school setting and it is vital that both the nurse and at least one other staff member are properly trained. This ensures that in the event the school nurse cannot be there, the other staff member can perform CPR until EMS arrives.

CPR Steps (13): 

1. Assess and ensure the scene is safe.
 
2. Have someone call 911 and grab an AED if available.
 
3. Check for breathing by tilting the student’s head back slightly and lifting the chin. Listen for no more than 10 seconds for breathing sounds (gasping is not a sound of breathing). If no breathing is heard, begin CPR.
 
4. Ensure that your hands are placed in the middle of the student’s chest, on their breastbone; hands should be placed one on top of the other.
 
5. Use your body weight to help administer 30 compressions that are 2 inches deep at a rate of 100 compressions per minute.
 
6. Deliver 2 rescue breaths by tilting the student’s head back slightly with the chin lifted. If you have a CPR mask, ensure a proper seal around the nose and mouth and blow into the 2-way valve. If no CPR mask is available, pinch the student’s nose closed and seal your lips over the student’s mouth. If no chest rise is noted with the first breath, re-tilt the student’s head before delivering the second breath. 
 
7. Continue the CPR steps until the student exhibits signs of life (breathing), an AED becomes available, or EMS arrives. 
 

AED Steps (14): 

1. Turn on the AED and follow the visual or audio prompts.
 
2. Open the student’s shirt and ensure their chest is dry. If the chest is not dry, quickly dry the chest off. If a student is wearing any medical patches, remove the patch and wipe the area where the patch was with a cloth. 
 
3. Attach the AED pads and plug them into the connector on the AED device
 
4. Make sure no one, including the one giving CPR, is touching the student. Inform everyone to “stand clear.” 
 
5. Push the “analyze” button on the AED and allow it to analyze the student’s heart rhythm
 
6. If the AED recommends a shock be delivered, ensure that no one, including the individual giving CPR, is touching the student. Tell everyone to “stand clear.”
 
7. Once everyone is clear, press the shock button on the AED. 
 
8. After the shock is delivered, immediately begin CPR again for 2 minutes. Continue to leave the AED pads on the student, as the AED device will continue to monitor and advise if a shock is needed. 
 
9. Discontinue CPR if the student exhibits signs of life (breathing), or EMS arrives.  

Conclusion


School nursing provides an autonomy that most nurses are not accustomed to. The school nurse is responsible for triaging, medicating, treating, assessing, and discharging students from their office. Understanding what medical emergencies may present to the nurse’s office and what you need to do for those emergencies is crucial. Quick actions and treatment can be the difference between life and death for a student. At the end of the day, seeing every student home safely is the sole purpose of school nursing.  

➁ Complete Survey

Give us your thoughts and feedback

➂ Click Complete

To receive your certificate