Introduction

One of the important functions of a school health program is to promote student health through early identification and detection of health problems that may result in disability and/or interfere with learning. When performed in concert with individual health assessments and continuing care, carefully planned and implemented screening programs are vital components of the school health program. Remember to get specific parental approval for all screenings.

School staff have frequent interaction with students, and this allows them to notice changes in appearance and behavior which may be related to a student's health status. School staff in their day-to-day contact with students should refer troubling behaviors or conditions to the school nurse or a medical provider if the school is without a nurse. A few examples include:

• Frequent absences
• Persistent fatigue
• Attention deficits observed in the classroom
• Fidgeting, noted as new behavior
• Skin eruptions or rash
• Frequent nosebleeds
• Deficiency in motor skills
• Emotional disturbances
• Obvious abnormal weight or height changes
• Shortness of breath

The school nurse’s frequent contact with students gives them an opportunity to detect differences in the health of individual students which might go unnoticed by others, even the student's family members.

Standards for Vision Screening in New Mexico Schools

In 2007, legislation was passed in New Mexico requiring all public schools to have a vision screening program. School vision screenings for the target population are required and defined under statute NMSA § 22.13.30 and New Mexico Administrative Code NMAC 7-30-11-8. This statute outlines that a school nurse or the nurse's designee, a primary care health provider, or a lay eye screener may administer a vision screening for students enrolled in the school.

The target grades are pre-kindergarten, kindergarten, first grade, and third grade. This also includes any new student or transfer student, unless a parent prohibits the visual screening.

Alternatively, at times individual students may be referred for a vision screening as part of an extended evaluation. These may be symptomatic students or students who are being evaluated for Special Education and a near-vision acuity evaluation is required for services. It should be noted that The National Center for Children’s Vision and Eye Health recommends that children with special health care needs should bypass vision screening and receive an eye examination from an eye care professional. Certain conditions increase the risk for vision disorders. These include, but are not limited to:

• Systemic medical conditions with ocular abnormalities, including diabetes mellitus and juvenile idiopathic arthritis
• Neurodevelopmental disorders, including autism spectrum disorder, Down syndrome, cerebral palsy, cognitive impairment, and developmental delay

To assist with this vision screening requirement, a fund was created to support school-aged children and youth to obtain vision examinations and glasses. This fund is managed by the NMDOH and is called the Save Our Children’s Sight Fund.

Contributions for the fund are furnished by New Mexico vehicle owners who have the option to donate either $1.00 or $5.00 to the Save Our Children’s Sight Fund at the time of vehicle registration. This fund is managed by the NMDOH Office of School and Adolescent Health (NMDOH OSAH). The current contractor for this fund is Lions Operation KidSight, Inc. Criteria for participation in the Save Our Children’s Sight Fund may be accessed through the New Mexico Lions KidSight website.

Parents may decline visual screening. Therefore, public schools are to provide advance notification of mass vision screening to include the screening date and location and an option to decline. New Mexico schools and districts may decide how to provide this advance notification. However, a declaration for the mass vision screening program has been included in the NM Emergency Contact and Health Authorization form. All New Mexico schools are encouraged to use the current year form. Public schools are required to submit to the New Mexico Public Education Department the total number of vision screenings performed and how many referrals were made. This reporting information can be found in the chapter for the Annual School Health Services Report within this School Health Manual.

Standards were developed to provide direction for vision screenings in New Mexico public schools and allow for multiple vision screening methods. Some examples of vision screeners are Basic Wall Charts, Spot Vision, PlusOptics, Optotype, Sloan Letters/Sloan Chart, and others.

It is recommended that the school nurse oversee the vision program to ensure appropriate training of all vision screeners, assessment of needs, referral, and care coordination follow best practice and standards of care. Below are some recommendations:

• The school nurse is to oversee the vision program.
• All non-school nurse vision screeners are to conduct only the first screening, with any necessary re-screening performed by the school nurse. Re-screening should be done within two weeks of the initial failed screening.
• For schools without a school nurse, the vision screener is to provide one vision screening, document the results, and notify the student’s parent/guardian of any failed vision screening with a recommendation for a vision provider examination.
• The school nurse is to make a referral to the parent/guardian for the student to have a comprehensive eye examination.
• The school nurse is to provide appropriate follow-up and case management for students referred for eye examinations.

Additionally, students should undergo a pre-screening observation before vision screening. Use the following referral criteria for the clinical observation.

Distance Visual Acuity Screening Procedures

Visual acuity is usually expressed in terms of a 20-foot testing distance. Charts or cards that are designed for use at 10 feet or another testing distance have been adapted to be equivalent to the 20-foot testing distance. Visual acuity is recorded as a fraction, such as 20/20. The top number, or numerator, represents the 20-foot distance measured from the chart to the floor marker. The bottom number, or denominator, represents the line on the chart the student can see. A result of 20/20 means that a student can see at 20 feet what should normally be seen at 20 feet. When visual acuity is abnormal, the bottom number will be higher, such as 20/50. Results are recorded for each eye separately.

• Chart illuminators are preferable if using a wall chart. If not available, position the vision screening chart in a room with good lighting.
• If possible, use a wall that is free of other distractions.
• Place the chart directly under fluorescent light or position a portable lamp to illuminate the chart.
• Place the chart with the passing or critical line at the student’s eye level, with no glare or shadows on the chart.
• Screen in a quiet, well-lighted area free of glare and distractions.
• Distance visual acuity wall charts are to be measured 10 or 20 feet from the student, as specified by chart instruction.
• The wall chart is to be at eye level of the student being screened and on a wall free of other visual stimuli.
• Identify students to be screened and provide any classroom pre-screening education that is needed.
• Students who wear glasses should wear glasses for general screening.
• Instruct the student to place heels on the marker or be seated with the back of the chair directly over the marker.
• Instruct the student to keep both eyes open when being tested.
• Instruct the student to cover the left eye with an occluder first to help the screener remember sequence.
• Begin with the line which is normal vision for the student being screened.
• Point to a symbol and ask the student to identify the symbol indicated.
• Move up or down on the chart as necessary until the student can identify the majority, one more than half, of symbols on any horizontal line.
• Repeat with the right eye occluded.
• Record findings in the student medical record.

Results/Referral Criteria

Students with results of more than one-line difference between eyes should be referred to an eye care specialist. Those with normal acuity in one eye and abnormal vision in the other eye should be referred. Follow-up on referrals is the responsibility of the school nurse.

Traditional Vision Screening Method

• Ages 4–5:
  • Required Test: Distance Visual Acuity
  • Suggested Testing Tool: LEA symbols or HOTV letters
  • Passing test line is 20/40
  • Refer if either eye tests 20/50 or above
  • Refer if more than one test line difference between the eyes
• Ages 6 and older:
  • Required Tests: Distance Visual Acuity, Ocular Alignment, and Color Vision
  • Suggested Testing Tool: LEA symbols or Sloan letters, Stereo FLY or Butterfly, Waggoner or Ishihara
  • Passing test line is 20/32
  • Refer if either eye tests 20/40 or above
  • Refer if more than one test line difference between the eyes
  • Ocular Alignment passing is identification of test object
  • Refer if failure to identify objects
  • Color Vision passing is identification of test objects
  • Refer if failure to identify objects

Ocular Alignment Screening Process

Ocular Alignment screening is to detect misalignment of the eyes. While the child focuses on a target, the examiner covers each eye sequentially to look for a shift in the alignment of the eyes. This screening requires a cooperative student, usually three years or older, and an experienced examiner. Required only once in any of the target population grades to be determined by the school and outlined in policy.

Results/Referral Criteria

Any student who fails to identify the test tool object should be referred for a comprehensive eye examination.

Reporting Results

Results are recorded as pass or fail.

Color Vision Screening Process

Color vision screening is required only once in any of the target population grades to be determined by the school and outlined in policy. Utilize the manufacturer’s instructions for the selected testing tool for the correct use of the tool and screener procedures. Typically, a color plate screening tool is used, such as the Ishihara color plate system. It is important to follow the manufacturer’s directions and screen the student with both eyes open and in a well-lighted area free of glare and distractions.

Results/Referral Criteria

Criteria for passing the screening will be dependent on the testing tool used. Parents should be notified if the student fails to pass color vision screening. In consultation with the parent, referral to an eye care provider might be considered for anticipatory guidance and development of coping strategies for this abnormality.

Reporting Results

Results are recorded as positive or negative for color vision.

Near Vision Acuity Screening Process

• This vision screening is only recommended to be conducted for a SAT meeting, Special Education referral, or re-evaluation.
• Identify a quiet, well-lighted area free of glare and distractions.
• Identify students to be screened and provide classroom pre-screening education as needed.
• Students who wear glasses should be screened with glasses.
• Display screening cards at 14 inches, or the recommended distance indicated for testing cards, from the student’s eyes.
• Place the card on a tabletop or hold it at test distance.
• Instruct the student to identify symbol(s) to which the screener points and begin with the symbol line which is normal acuity for the age of the student being screened.
• Screen the student with both eyes open.

Refer to testing device criteria information. Near vision acuity testing is done with both eyes open. Students must identify 80% of letters or symbols on the critical line of 20/30. Near vision tests are not completely accurate for use in testing children under age 10 because of the accommodative power of the eye in this age group. Near vision cards may identify students with astigmatism because symbols will be blurred.

Vision-Related Definitions

O.D.

Right eye, oculus dexter.

O.S.

Left eye, oculus sinister.

O.U.

Each eye, oculus uterque; or both eyes, oculi unitas.

Blind

No usable or functional vision.

Legally Blind

Usually acuity of 20/200 or worse with best possible correction. Federal guidelines indicate eligibility for services available for persons with severe, non-correctable vision defects and visual acuity.

Cortically Blind

Neurologically-based vision defect. The visual system is intact, but the individual has sustained brain damage that prevents the brain from properly processing and interpreting the visual image and information taken in by the eye. The individual may have some usable or functional vision, including light perception and blink reflex.

Amblyopia or Lazy Eye

Amblyopia is identified by stereopsis testing and distance vision tests. It is a condition that, if not discovered and treated before the age of 6 or 7, usually leads to permanent reduction of vision in the affected eye. An eye with amblyopia has dimness of vision without any apparent disease of the eye. It is often caused when one eye turns in or out while the other sees straight, known as strabismus, so that a double image is sent to the brain. It may also be associated with a marked difference in the refractive error of each eye, known as anisometropia, resulting in two images. The brain solves this confusion by ignoring the message from one eye that gradually weakens through disuse. The usual treatment is patching the good eye in order to force the use of the weaker one. Sometimes this is combined with glasses, surgery, medication, or eye exercises.

Anisometropia

Unequal refraction of the two eyes. Anisometropic eyes may have myopia or hyperopia but of different degrees, or one may be myopic and the other hyperopic. Marked anisometropia is a common cause of amblyopia because the eye with the greater refractive error is ignored.

Astigmatism

An eye refractive error problem resulting in blurred vision because of the irregular or defective curvature of the cornea or the lens causing a distorted image because light rays cannot focus on a single point of the retina. Astigmatism affects vision at all distances. It may be associated with myopia or hyperopia. Most cases of astigmatism can be corrected with glasses or contact lenses.

Color Deficiency

An inherited vision defect. It is not a disease; it is characterized by the inability to recognize certain colors, primarily red or green, but rarely blue or yellow. Deficiency in this visual function is not correctable. It is important for students, parents, and teachers to be aware of this condition to help the student develop appropriate coping mechanisms.

Hyperopia

Farsightedness. This is identified by near vision tests. Hyperopia is a refractive error in which the light rays focus behind the retina, either because the eyeball is too short or the lens is too thin and flat and does not bend the light rays enough. The result is that students who are farsighted see better at a distance than close-up. This condition can be corrected with glasses or contact lenses.

Myopia

Nearsightedness. This is identified by distance vision tests. Myopia is a refractive error in which the light rays are bent and focused in the front of the retina, either because the eyeball is too long or because the lens is too thick and curved so that it bends the rays too much. As a result, students who are nearsighted see better close-up than at distances. Myopia is usually first seen in children 6–8 years of age. It can be corrected with glasses or contact lenses.

Strabismus

Squinting. It is identified by ocular alignment and stereopsis testing. Strabismus is the term used to describe eyes that are not straight or properly aligned due to a muscle imbalance. One eye, or sometimes both, may turn in or turn out. It cannot be outgrown, nor will it improve by itself. An eye deviation that persists without treatment may result in permanent visual impairment because the vision in one eye is suppressed, causing amblyopia. Treatment directed toward straightening the eyes can involve glasses, patches, eye drops, surgery, or eye exercise.

Vision Screening Resources

• National Association of School Nurses and National Center for Children’s Vision and Eye Health at Prevent Blindness. (2022). Vision and Eye Health.
• National Association of School Nurses and VSP Vision Eyes of Hope. Gift Certificate Program.
• National Center for Children’s Vision and Eye Health at Prevent Blindness. About the National Center for Children’s Vision and Eye Health.
• Prevent Blindness. (2021). About Prevent Blindness.

Standards for Hearing Screening in New Mexico Schools

The purpose of a general hearing screening program is to identify students who have hearing impairments that interfere with or have the potential for interfering with communication and learning processes. Authorities generally agree that early detection of medically-remediable hearing loss helps to prevent related problems in speech and in social and educational development.

There are no mandatory hearing screening requirements, unlike with vision screening. It is recommended that schools provide general and individual hearing screenings based upon the following:

• The school is to define a hearing screening program in policy and procedure defining the hearing program manager or coordinator, hearing screeners, and hearing screeners’ training.
• Utilize the American Speech, Language, and Hearing Association's Guidelines for Manual Pure-Tone Threshold Audiometry and the National Association’s recommendations and hearing screening standards.
• The school nurse is to provide oversight of hearing screening and follow-up in the schools.
• The identification of hearing problems is accomplished by using individual pure-tone air conduction testing. For more information, see ASHA’s Pure Tone Testing.
• Acoustic immittance screening might also be considered if trained staff are available.

A well-balanced program will include screening and re-screening threshold audiometry as well as referrals for audiological or medical evaluations.

Students identified with hearing abnormalities should be followed on a regular basis to ensure that their communication, educational, and medical needs are met. Education and habilitation planning and counseling for parents and teachers should be implemented.

The target population for hearing screening is a recommendation and not a mandate. The following target population is recommended for pure tone hearing screening:

• Pre-school students;
• Kindergarten students;
• First-grade students;
• Third-grade students;
• Eighth-grade students;
• High-risk students;
• New students with no documented evidence of prior hearing screening at the designated grade levels; and
• All students being referred for special education evaluation.

Recommended Hearing Screening Procedures

Pure Tone Conduction

A pure-tone audiometer, calibrated to published audiometric standards, is required for reliable pure tone conduction testing. See Kutz, Jr., J. W. (2018). Audiology pure-tone testing. Medscape.

Audiometers are delicate electronic devices and can easily be damaged. The audiometer needs routine maintenance and accuracy checks by qualified technicians. All audiometers should be electro-acoustically checked and serviced, and returned to the factory if necessary, at least once a year and more often if a malfunction is suspected.

Pure tones are described in terms of pitch or frequency:

• Hertz (Hz) equals units that define frequency.
• Loudness is measured in decibels (dB).

Screening Method

The Sweep Test is the preferred pure tone conduction hearing screening. It is a screening measure whereby pre-selected frequencies are presented at pre-determined levels, and the student is asked to give a response each time the tone is heard. The series of frequencies are presented first in the right ear, and then in the left. Each student is tested individually. Time intervals between the presentation of each tone must vary for the screening results to be reliable.

The audiometric equipment should be checked before testing to verify that it is working properly. The test environment should be as quiet as possible. The recommended frequencies for sweep testing include 1,000, 2,000, and 4,000 Hz presented at 20 dB, using the following steps as procedural guidelines.

• Set the intensity hearing level dial at 20 dB.
• Set the audiometer on “reverse” or “tone off” so that the sound goes through the earphone only when the tester pushes the tone switch.
• The student should be positioned so that the tester’s hand and eye movements cannot be observed.
• Instruct the student to raise a hand when tone is heard and lower the hand when tone disappears.
• Keep instructions simple. The student unable to raise a hand can respond by dropping a small object, such as a block, into a container. An oral response, “yes,” is also acceptable.
• Earphones should be placed on the student by the tester to assure proper fitting so that the earphone is centered over the ear canal. Care should be taken to prevent obstructing the ear canal or folding the ear.
• Provide a sample tone of loud intensity, such as 200 Hz at 40 dB, to ensure that the student understands what is meant by the word “tone.”
• Provide the student opportunity to ask questions.

The suggested order of presenting tones is 1,000, 2,000, and 4,000 Hz. The student fails the sweep test if one of the tested frequencies cannot be heard in one ear at the recommended decibel level. At this point, an otoscopic exam should be performed. Signs of abnormalities such as otitis media, tympanic perforation, or cerumen impaction warrant a medical referral. However, a student without any abnormalities on otoscopic exam should be scheduled for a repeat test at a later time; allow three weeks between screening tests. A second failure at the pure-tone conduction hearing screening warrants a medical referral.

Impedance audiometry, also known as tympanometry and acoustic immittance, provides information about the middle ear. Impedance audiometry is a valuable diagnostic tool, but it is not usually included in hearing screenings. This measure is optional in school screening programs, but it should not be substituted for pure-tone audiometric testing. It may be used for very young students and students who are difficult to screen.

For more information, see Dr. Jasmine Shaikh, MD (2023), What is the purpose of impedance audiometry.

Recommended Rescreening and Referral Criteria

Audiometry screening results should be properly documented as pass/fail and for each ear separately. Observational factors such as frequent earaches, draining ears, excessive cerumen, mouth breathing, and decreased responsiveness in the classroom should all be considered when making a medical referral. The referral process should be initiated ideally by the school nurse, with a referral form sent home to the parents. The referral form is to include any observations of school personnel in addition to screening results.

Hearing Referrals and Assessment

The form should be accompanied by at least one audiogram showing abnormality, along with observations, history, and explanation for referral. Any referral should be accompanied with a request that the School Nurse receive a follow-up report to enhance any anticipatory guidance efforts with the parents and school staff that might be appropriate.

Audiological Assessment

The evaluation report on a student who has been referred by the School Nurse and tested by the audiologist will contain valuable information about the individual’s ability to hear speech. Under controlled conditions, the student is tested on the ability to hear spoken words that are repeated to the audiologist.

Signs and Symptoms of Hearing Problems

The classroom teacher plays an important role in recognizing and reporting students who show symptoms of possible hearing loss. Students who present with the following may have trouble hearing and should be referred to the School Nurse for further evaluation.

• Draining ears.
• Ears filled with dried wax or crust from draining ears.
• Inflammation in or around the ear.
• Mouth breathing.
• Upper respiratory allergies.
• Cleft palate.
• Chronic colds.
• Chronic ear infections.
• Mastoiditis and meningitis.
• Neonatal history, including low birth weight, prematurity, or perinatal infections.
• Pain in or around the ear.
• Ears “stopped up.”
• Ringing or buzzing in ears.
• Asks speaker to repeat.
• Turns head to side when listening.
• Leans forward when listening.
• Stares intently at speaker.
• Appears confused or bewildered when listening to speaker.
• Hears better when directly in front of speaker.
• Interrupts conversation, not aware that others are talking.
• Has trouble with oral directions.
• Performs better on written work than oral work.
• Has poor diction and/or articulation.
• Withdraws from group activities when hearing is required.
• Doesn’t pay attention. Some students may develop a habit of inattention even when hearing is normal; however, presence of inattention should not be dismissed, and the student should be given a hearing test.

Classroom Considerations for the Hearing-Impaired Student

It is essential that the teacher understand a student’s hearing problem. It is also important to establish a feeling of acceptance for the hearing-impaired student. The teacher should be alert for signs of improvement or deterioration in hearing and be willing to discuss these observations with the School Nurse and/or parents.

Significance of Hearing Loss

The degree of difficulty the student experiences will depend upon the amount and type of hearing loss. Students who have trouble hearing speech sounds may be unable to follow directions. It is likely that they will make mistakes in spelling and will have difficulty producing some of the speech sounds correctly. Students with severe hearing loss often have trouble listening. If the student has a hearing loss in only high tones, some sounds may be heard well and others poorly. Often, high-tone loss results in failure to hear the following speech sounds: Sh, Ch, Th, S, F, V, and J.

Unilateral Hearing Loss

Hearing loss in one ear will create difficulty locating the direction from which the sound originated, particularly when there is loud background noise. Classroom noise may keep the student from hearing directions correctly. It is also important that the student with unilateral hearing loss be reminded to take care when walking or playing in traffic areas or on the playground.

Hearing Aid Users

Hearing aid wearers may be distracted by environmental noise, creating difficulty in following conversations in a group. In a classroom with a student wearing a hearing aid, the teacher should understand the mechanics of the hearing device to ensure it is being effectively utilized and assist in troubleshooting with any problems.

Seating Considerations

For bilateral hearing loss, seat the student directly in front of the teacher. For unilateral hearing loss, seat the student close to the instructor with the normal ear toward the source of instruction.

Speaker Awareness

It is important to patiently restate and rephrase when the student does not understand. Do not stand in glare, for example near a window. Face the student when speaking and when using a writing board. Face the class when providing explanations. Speak slowly and distinctly, speaking naturally and not exaggerating lip movements. Speaking too loudly may be especially disturbing to the hearing aid wearer. Use FM voice projection equipment, if available, and use lapel microphones, as appropriate and available.

Tips on Giving Directions

• Acquaint the student with any new vocabulary when a new topic is introduced and get the student’s attention before giving directions.
• Ensure that the student understands the directions and encourage the student to request that directions be repeated if necessary.
• Provide opportunity for the student to repeat directions.
• Use written directions if the student has continued difficulty understanding.

Special Considerations

Fatigue may be a factor because hearing impairment requires extra concentration to receive information. Language development may be challenging because many words and ideas have no meaning if the student is unable to hear the words. Encouraging the hearing-impaired student to do extra reading, spelling, creative writing, etc. may help compensate, but it is not uncommon for these students to exhibit delays in language development.

Hearing Screening Resources

• Familiar Sounds Audiogram
• Hearing Screening Form

Required Student Dental Examination

Upon initial enrollment in a district or charter school, New Mexico Administrative Code requires schools to verify student records of dental examination under NMAC § 6.12.13. This rule also allows for an informed opt-out process based on the parent/guardian understanding the risks associated with not having a dental examination. The following requirements from the New Mexico Public Education Department are available for school use:

• Summary of Student Dental Examination Requirements for Enrollment
• Sample Enrollment Form Waiver — English
• Sample Enrollment Form Waiver — Spanish

Height/Weight/BMI Screening Overview

In New Mexico, 22.9% of third graders have obesity, based on 2019 data, and children with obesity are more likely to develop chronic disease as adults. In New Mexico, 26.1% of adults over 45 years old were living with multiple chronic conditions, based on 2017 data. With the ongoing occurrence of childhood obesity, attention is increasingly focused on height, weight, and BMI measurement programs in schools.

There are two types of height/weight/BMI measurement programs in schools: screening and surveillance. BMI screening programs measure individual students to identify at-risk individuals and provide those students and their parents with information to help them take appropriate action. BMI surveillance programs assess the weight status of a specific population, such as students across the state, to identify the percentage of students potentially at risk for weight-related health problems.

Screening

The New Mexico Administrative Code does not require New Mexico schools to do height/weight/BMI screening of students. The NMDOH Medical Oversight Committee position statement does not endorse school personnel to engage in mass screening of students for height/weight/BMI measurements. There is not enough evidence demonstrating that school-based BMI screening is an effective or cost-effective strategy for reducing childhood obesity. Screening requires medical follow-up and nutritional referrals, which is impractical for communities with limited resources.

Surveillance

NMDOH conducts height/weight/BMI surveillance in schools under specialized programming where costs are minimized, safeguards are well established, and data is anonymous. Data collected is used to identify at-risk populations, track data trends, and implement evidence-based strategies to reduce childhood obesity. Participating schools receive a summary of their results, which they can use to promote appropriate health strategies for their school. Schools have the option to participate in NMDOH surveillance of height/weight/BMI, which is endorsed by the NMDOH Medical Oversight Committee.

The CDC offers further explanation on BMI measurements in schools, including guidance on necessary safeguards for schools considering participating in surveillance programs: Body Mass Index Measurement in Schools.

Scoliosis Screening Overview

Because of the literature review on recommendations for scoliosis screening and assessing priorities for the evolving role of school nurses, the following recommendations were issued by memorandum by the DOH Chief Medical Officer in 1995, and they are NMDOH's current recommendation. Mass scoliosis screening should not be done in schools, and scoliosis evaluation is best performed by a medical provider when examination for other reasons takes place. Schools that choose to conduct scoliosis screening based on special concerns of parents, school, or community are to be properly trained and establish a follow-up referral system for students with positive and/or suspicious findings.

School Blood Pressure Screening Overview

The New Mexico Administrative Code does not require New Mexico schools to conduct mass blood pressure screenings for students, and the NMDOH Office of School and Adolescent Health does not recommend mass screening of blood pressure. A blood pressure measurement is to be taken by a School Nurse, or delegated to a health assistant, because of symptoms that could be associated with a blood pressure issue. The need for a blood pressure reading is to be based upon a nursing assessment and/or student-specific medical orders.

General Guidelines for Blood Pressure Measurement

It is important for the health care provider to measure blood pressure accurately, using the correct equipment and technique.

• Have the student sit in a quiet environment for a few minutes before taking a blood pressure reading.
• The student is to be seated with their back and feet in a supported position.
• It may be necessary to measure the blood pressure a few times, several minutes apart, to get the most accurate reading.
• Take the blood pressure reading only if the student is not upset, crying, or unable to cooperate, to avoid an inaccurate reading.
• Use the appropriate size cuff.
• Measure blood pressure in the right arm unless contraindicated.
• Stimulants such as cigarettes and caffeine are to be avoided for several hours before blood pressure is measured.

Defining Hypertension in Children and Adolescents

Hypertension in pediatrics is not common. The proper management of childhood hypertension depends on prompt recognition and treatment. Inadequate awareness of pediatric blood pressure norms, poor technique resulting in inaccurate measurements, or failure to obtain blood pressure measurements can all prevent or delay recognition of this clinical condition.

The U.S. Department of Health and Human Services provides general guidelines for school nurses to use when interpreting a blood pressure for students. This information provides generalized guidance only and should not be used as a definitive evaluation or diagnosis of blood pressure status.

For more information, see: U.S. Department of Health and Human Services; National Institutes of Health; National Heart, Lung, and Blood Institute. (2005). The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents.

Overview of Special-Needs-Related Assessments

Response to intervention, or RTI, is a process used by educators to help students who are struggling with a skill or lesson. Every teacher will use interventions, a set of teaching procedures, with any student to help them succeed in the classroom. It is not just for children with special needs or a learning disability.

In New Mexico, the RTI framework is set forth in state rule for all public district and charter schools. It is known as the three-tier model of student intervention, in which the intensity of instruction and assessment increases as students are served in the next-higher tier. Students who struggle academically may also exhibit behavior problems and vice versa. For that reason, both academic and behavioral systems are addressed, in a concerted effort, in all three tiers:

• Tier 1: Universal screening, appropriate core instruction with universal intervention. Approximately 80% of students needing assistance are in general education and may need vision/hearing screening and general health screening or comprehensive health assessment by the School Nurse.
• Tier 2: Student Assistance Team (SAT) process, which includes targeted individualized interventions determined by the SAT team for referred students that may need a 504-accommodation plan.
• Tier 3: Special Education/Gifted Education targeted for few students requiring intensive and specially designed instruction and services for students who qualify for Special Educational Services under an Individualized Education Plan.

Students referred to a SAT will need, at a minimum, a health screening that includes a vision/hearing screening or health assessment before the SAT team convenes for the referred student, in order to determine that vision or other health-related needs are not the reason for the student’s inability to succeed in the classroom.

Only a School Nurse may conduct a comprehensive health assessment. However, a Health Assistant or designated trained personnel may participate in a student’s health by conducting the initial vision or hearing screening for students being evaluated or re-evaluated for Special Education, developing a process for managing these referrals with Special Education.

Development of Comprehensive Health Assessment

The initial step in developing a comprehensive Health Assessment is for the School Nurse to conduct a thorough health history. The student health history provided by the parent/guardian of each student should include medical diagnosis and medications.

Initial Health History/Nurse Assessment Guidelines

To obtain a complete medical history of the student, it is recommended that the Initial Student Health History form be completed either by the parent/guardian or by the School Nurse through a telephone or in-person interview. If this is not possible, the Initial Student Health History form may be sent home with instructions to complete and return it so that screening may proceed.

• Document any unsuccessful attempts to obtain health history information in the student’s medical record.
• Develop student-specific Individualized Health Plans or Emergency Care Plans and forward confidentially to any designated Special Education staff with a “need to know.”
• Do not delay the educational testing process due to the inability to obtain health assessment information.
• All findings, recommendations, and comments can be documented on the Nurse Screening.
• Student Health Assessment forms and Initial Health History forms should always be a part of the student health file.

Nursing Assessment for Special Education Students

It is recommended that only the School Nurse be responsible for health assessments and screenings for any students being evaluated or re-evaluated for Special Education. When nursing services are required for the student to benefit from special education services, nursing services are considered a related service like occupational therapy, speech therapy, or physical therapy.

It is important to develop a district-level or school-level process for the School Nurse to be able to identify students referred for Special Education services that might have health-related conditions or needs that may potentially influence Special Education, in order to prevent missed opportunities to intervene. This will allow for the evaluation to flow in a timely fashion for all parties involved, for the process to begin at the beginning of each school year, and for referrals to occur at least ten school days prior to diagnostic evaluation or re-evaluation for Special Education service. Using a tracking form will help keep the referral process organized and on time. It is also important to have teachers and diagnosticians log requests and submit referral forms appropriately to prevent confusion.

The following general guidelines are intended to assist the School Nurse in organizing her/his role in the process:

• The School Nurse is to be notified in a timely fashion of students who are being referred to Special Education with potential health-related needs for a comprehensive nursing assessment.
• The School Nurse is to obtain parental consent to perform screenings and complete a comprehensive nursing assessment and student health history interview for each referral.
• The school is to complete a student health history and conduct a comprehensive student health assessment after parental/guardian consent. This assessment should include vision and hearing screening results and a general health assessment within 10 school days after receiving the referral and parent/guardian consent.
• When completing the Student Health Assessment form, it is appropriate to utilize vision and hearing screening results that have been completed within the current school year rather than repeating them. At the discretion of the School Nurse and based on student complaints or symptoms, a physical assessment may be performed and/or a referral made to a medical provider for the assessment. Any School Nurse concerns should be shared with the parent/guardian with a request for follow-up with a medical provider if appropriate.

Health Assistants cannot be delegated to conduct a comprehensive health assessment since assessment and care-plan development is an exclusive function of a Registered Nurse under the New Mexico Nurse Practice Act. However, Health Assistants, when appropriately trained and when requested to participate, may assist the School Nurse in collection of information to complete portions of the assessments.

Individual Educational Plans and Adding Services

An IEP meeting is always necessary to request an evaluation for related services, including nursing services, for a student already in Special Education. If the student qualifies for related services and an IEP meeting is scheduled, and nursing services may be needed, the School Nurse may need to attend if it is not an annual IEP. If the related services are not nursing services, an evaluation for physical therapy, occupational therapy, adapted physical education, assistive technology, or another related service other than nursing services or speech and language pathology, then the School Nurse need not be involved and no additional assessments or health history are to be provided by the School Nurse.

When a student is referred for an evaluation by speech-language pathology, the School Nurse should review the student’s health record and perform a hearing screening if one has not been done within the current school year. Failure to pass the hearing screening should result in a referral for audiology evaluation, with results documented in the student health record and shared with the school speech-language pathologist.

To change or delete health services on an IEP, an addendum may be added to the existing IEP. This does not require a full formal IEP meeting with all staff. It is acceptable for the School Nurse, Special Education representative, and the parent to meet, discuss, and make changes to the IEP regarding school health services. The School Nurse is responsible for reviewing the student’s health record and documenting any significant information on the IEP.