Introduction

Some students with special needs have conditions that have been diagnosed prior to school entry, while others are detected as a result of mass screening, medical, and/or psychological examinations at school. It is important to encourage parents to seek adequate and complete evaluation and treatment for all conditions.

Every school has among its population students receiving special education services or students identified as learning-disabled. A school health program is incomplete if provision is not made for the identification of these students and for the adaptation of the regular school program to meet their needs. Without such adaptation, the physical and mental well-being of the student may be further impaired, and the student may be unable to take full advantage of educational opportunities provided by the school.

Students receiving special education services because of health conditions may stay in the special education program through age 21. When rehabilitation services for students age 18 or over are needed, the Division of Vocational Rehabilitation should be contacted during the student’s final year in school to facilitate transition of services.

State laws mandate that a system for screening the general school population be developed to identify students who have special needs. Based on screening findings, educational alternatives may need to be considered. A student assistance team will evaluate each individual case and assess the need for an educational plan of alternatives. Educational alternatives may include, but are not limited to, classroom modifications, referral to bilingual programs, reading/tutoring programs, counseling, and/or a referral for special education evaluation.

Modifications in the general education school program will be made to the maximum extent appropriate to enable identified students to remain with his/her general class. Assignment to special classes or schools should be kept to a minimum. All students in special classes will be directed to join general classes whenever feasible, and when in agreement with the student's Individualized Education Program (IEP). The educational placement of students should be periodically re-evaluated to assure that appropriate and timely modifications are made.

Students with Chronic Health Conditions

Per the CDC, more than 40% of school-aged children and adolescents in the U.S. have at least one chronic health condition, such as asthma, obesity, other physical conditions, and behavior/learning problems. The health care needs of children with chronic illness can be complex and continuous and include both daily management and addressing potential emergencies.

The CDC has developed strategies and funded research to help schools address chronic health conditions that impact learning and overall well-being. Many students with chronic health care conditions will require services through special education and still need to have strong school health services to maximize learning. It is important to assess the school’s ability to provide these services, and the School Health Service Teams Assessment can be used as a tool.

Resources for Chronic Health Management in Schools

• National Center for Chronic Disease Prevention and Health Promotion. (2017). Health insurance for children: How schools can help. Centers for Disease Control.
• National Association of School Nurses. (2020). Skills-based approach to managing chronic health conditions in schools. Online course.

Individualized Education Program (IEP)

The NMPED addresses federal and state regulations for special education programs and processes with additional information obtained from the NM Public Education Department Standards of Excellence Compliance Manual, which should be available through any school district administrative office.

The IEP is defined in NMPED regulations as a written statement for a child with a disability that is developed and implemented. The IEP is required to be in place before special education services can be delivered to a student. Each public school is responsible for initiating and conducting meetings for the purpose of developing, reviewing, and revising a student’s IEP, with review meetings occurring at least once a year. Timing of such meetings is left to the discretion of each school, if IEPs are in effect at the beginning of each school year. The review meeting may be held on the anniversary date of the student’s last IEP meeting.

Schools are required to include the following participants in an IEP meeting:

• Representative of the school other than the student’s teacher who is qualified to provide or supervise provision of educational services.
• The student’s teacher.
• One or both of student’s parent/guardian.
• The student, when appropriate.
• Related ancillary service providers, which might include a registered nurse, occupational therapist, physical therapist, psychologist/psychiatrist, nutritional services, social worker, etc.

In addition, for a child with a disability being evaluated for the first time, evaluation personnel should be included in the IEP meeting. The school is responsible for ensuring that a member of the evaluation team participates in the meeting or that the representative of the public school, the child’s teacher, or some other person is present at the meeting who is knowledgeable about the evaluation procedures used for the child and is familiar with the results of the evaluation.

The School Nurse, as part of the IEP team, provides nursing and medical assessment data and facilitates any additional medical evaluations when necessary. This nurse is responsible for completing the nursing assessment forms in a timely manner to facilitate the referral process, and it is a requirement that the School Nurse be included in the IEP process when there are medical issues relevant to the educational process. The School Nurse is not responsible for delivery of school health services written into the IEP if not involved in the development of the plan.

Vision screening includes near and distance vision, stereopsis, motility, and color discrimination. Refer to the vision screening guidelines in Chapter 3. Hearing screening is conducted with a pure-tone audiometric device and is to be conducted at 500, 1,000, 2,000, and 4,000 Hz. Refer to the hearing screening guidelines in Chapter 3.

A health assessment, to include a health history, is to be performed by the School Nurse. This includes height, weight, vital signs, head circumference as recommended for age or medical indication, as well as neurological screening assessment. Refer to the screening assessment in Chapter 3.

State Programs for Children with Special Health Care Needs

Children's Medical Services (CMS)

The NMDOH Children’s Medical Services (CMS) licensed medical social workers coordinate health, medical, and other community resources to develop and meet child and family goals. CMS sponsors community-based University of New Mexico Health asthma, cleft palate, genetic, metabolic, gastroenterology, cardiology, nephrology, neurology, and endocrinology clinics throughout New Mexico, creating needed access to pediatric and youth specialists.

Insurance, language, transportation, and any other barriers or challenges are addressed by CMS staff with enrollment in CMS. If a referral to CMS is indicated, please engage the family as CMS is a voluntary program. An intake form or telephone referral can be made to the local DOH/PHD/CMS office.

Contact Information for CMS: https://nmhealth.org/about/phd/fhb/cms

Services Provided by CMS

• Access to care for children with special health care needs in New Mexico who are ineligible for Medicaid funding and whose families are unable to afford insurance.
• Diagnostic evaluations to determine program eligibility.
• Care coordination for children and their family.
• Care for children with a genetic condition.
• Payment of medical services such as primary care, hospitalization, surgery, or other prescribed treatments for those who meet the financial/medical eligibility.
• Access to Multidisciplinary Pediatric Specialty Outreach Clinics:
  • Cleft Lip and Palate.
  • Endocrine.
  • Pulmonary/Asthma.
  • Nephrology/Renal.
  • Genetics/Dysmorphology.
  • Cardiology.
  • Neurology.
  • Metabolic.
  • Gastroenterology.
• Adult Cystic Fibrosis care coordination/medical management.
• Increased access to medical homes for children with special health care needs.

CMS Eligibility Guidelines

Medical Eligibility

• New Mexico residency for children from birth to 21 years of age.
• Diagnosis or potential diagnosis of a condition listed in the CMS Medical Eligibility Guidelines that includes the following categories:
  • Childhood Cancers.
  • Congenital Internal Organs Anomalies.
  • Ears, Nose, and Throat Disorders.
  • Endocrine Disorders.
  • Gastrointestinal Disorders.
  • Genetic Disorders.
  • Hematologic Disorders.
  • Lead Screening and Treatment.
  • Neurologic Disorders.
  • Ocular Disorders.
  • Plastic Surgery Conditions.
  • Pulmonary Disorders.
  • Renal and Urinary Tract Disorders.
  • Rheumatic Disease.
  • Skin Disease – Chronic.

Financial Eligibility

• At or below 200% Federal Poverty Level.
• Ineligible for Medicaid funding.
• None for diagnostic work-up.

Safety Risks Associated with Special Needs

Safety considerations in the school setting should be designed to help students who have health conditions or special needs become as independent as possible, while protecting the individual student’s safety and well-being, as well as that of the rest of the student body and school staff.

A school support/educational team meeting for students who meet the criteria for 504 placement is the appropriate place to address safety concerns and precautions that should be taken with each individual student. For special education students, these concerns are addressed in the IEP conference or annual review. All educational team members, including the School Nurse, administrator, and parent/guardian, should participate. Risk factors must be determined on a case-by-case basis and documented on the IEP.

Obtain written guidelines in the Individualized Healthcare Plan (IHP) outlining when, where, how often, how much, and under what circumstances special supervision, physical assistance, and/or use of protective equipment is needed. An Individualized Emergency Evacuation Plan should be written if indicated. All safety precautions should be posted in the student’s classroom so that the information is readily available.

Procedures to protect the health, safety, and well-being of students during off campus activities, including field trips, swimming, therapeutic horsemanship, and community-based work experience, must also be addressed. If the student is in special education, these procedures must be addressed at the IEP conference.

Hygiene Program

Care and cleanliness of the entire body including skin, hair, nails, teeth, and clothing to promote good health and a pleasing appearance are part of a personal hygiene program. Although all students should be aware of personal hygiene, especially in the adolescent years, special needs students may require additional attention to personal hygiene issues.

Personal hygiene and good grooming skills are essential to the development of good health habits and self-esteem. They need to be incorporated into the special education student’s IEP goals, if needed. Goals for teaching students such skills should be individualized.

Chronic Health Conditions and Syndromes

Asthma

Asthma is a chronic condition in which airflow in the bronchial tubes becomes periodically obstructed, making breathing difficult. Obstruction can be caused by bronchospasms, or tight contractions of the respiratory muscles around the bronchi, by swelling and inflammation of the membranes lining the bronchi, and by plugging of the tubes with thick, sticky mucus produced by the bronchial gland.

Recommended Guidelines

The School Nurse should assume the following responsibilities when creating a follow-up plan for students diagnosed with asthma:

• Obtain a complete asthma health history.
• Obtain a health care provider’s recommendations for care in the school setting.
• Complete a nursing assessment.
• Develop an Individualized Healthcare Plan (IHP).

Documentation of any asthma episode should include the following information:

• Time of onset of symptoms.
• All presenting symptoms.
• Peak flow meter readings, if applicable and if a peak flow meter is available. See Asthma Action Plan tool for peak flow measurement procedure.
• Response to medication given.
• Care outcome.

The School Nurse can help reduce staff and peer anxiety level regarding students’ needs by including the following information in education sessions:

• Definition of asthma.
• Common triggers and ways to minimize exposure to them in the classroom.
• Early warning signs of an asthma attack/episode.
• Need for prompt, calm treatment when an attack/episode occurs.
• Encouragement for full participation in all academic, physical education, and extracurricular activities with modifications, if necessary.

It is recommended that the school emergency action plan include identification of CPR-certified personnel. If a student experiences repeated episodes, inability to tolerate physical activity, increased school absences, emergency room visits, and hospitalizations, then this suggests inadequate medical management. A recommendation to follow up with the student’s medical providers is indicated.

Resources

• American Academy of Asthma, Allergy and Immunology. (2016). School-based asthma management program: SAMPRO.

In addition to the asthma management manual, additional tools to assist in carrying out these responsibilities can be found in the Resources Section for Chapter 4.

Atlantoaxial Subluxation

Atlantoaxial subluxation is a separation at the axis of the first cervical vertebra and odontoid process. If separation exists to a great enough degree, usually 4.5 mm or more, compression of the spinal cord could occur during hyperextension, hyperflexion, or pressure of the head, neck, or upper spine.

The American Academy of Pediatrics (AAP) released a position statement recommending radiologic screening of the cervical vertebrae in children with Down Syndrome. In 1995, the AAP retired their 1984 position statement after reviewing the evidence regarding the efficacy of radiologic studies.

The findings from x-rays of the neck are not consistently reproducible. Furthermore, radiologic evidence of subluxation has not been associated with subsequent neurologic problems. Rare but serious neurologic problems have developed in a few Down Syndrome children with prior normal x-rays, with or without involvement in sports activities. Therefore, the decision to obtain cervical x-rays in the asymptomatic student is made by the primary care provider and parents. It is no longer routine for all Down Syndrome students to have cervical x-rays prior to sports activity.

What seems to predict subsequent serious sequelae more reliably are subtle neurologic signs and symptoms. Some of the children who have suffered long-term neurologic deficits had a prior history of changes in gait, torticollis, neck pain, enuresis, progressive hemiparesis, increased lower extremity tone, and upgoing toes on a neurologic exam.

Management of students with positive x-rays will be in accordance with their physician’s recommendations and may include exclusion from certain activities that increase risk for injury to their spinal cord.

Attention Deficit Hyperactivity Disorder

Attention deficit hyperactivity disorder (ADHD) is one of the most common childhood brain disorders and can continue through adolescence and adulthood. It is characterized by a variety of manifestations, often including more than one of the following:

• Lack of selectivity in attending to stimuli.
• Impaired focus.
• Constant activity.
• Sleep disturbances.
• Short attention span.
• Distractibility.
• Inattention.
• Impulsiveness.
• Performance inconsistency.

These symptoms can make it difficult for a child with ADHD to succeed in school, get along with other children or adults, or finish tasks at home. It is normal for all children to be inattentive, hyperactive, or impulsive sometimes, but for children with ADHD, these behaviors are more severe and occur more often. To be diagnosed with the disorder, symptoms must have been present before the age of 12. Children up to the age of 16 are diagnosed if they have at least six persistent symptoms of inattention and/or six persistent symptoms of hyperactivity-impulsivity for at least six months. Most students with ADHD are diagnosed in early childhood. Behavioral issues at all ages should be carefully evaluated for learning disabilities, undiagnosed closed head injury, mental health issues, and family problems.

Recommended Guidelines

The school is responsible for obtaining a complete health history. Educational staff observations should be provided to the medical provider for determination of the correct diagnosis and treatment. The school should obtain medical records and provider recommendations for services to be provided while in the school. Treatments aim at reducing symptoms of ADHD and improving functioning in the school environment, which should be a mix of psychotherapy, education, and combination treatments.

Assessments should include the following:

• Efficacy, including longer attention span and increased tolerance to distraction, usually noticeable within the first week.
• Side effects of medication, including height, weight, and blood pressure.

Specific ways to assist the student who has ADHD include the following:

• Prepare the student ahead of time for changes in routine or special events.
• Provide appropriate ways for the student to expend physical energy.
• Minimize situations involving excessive noise, disorganized activity, unstructured time, and classroom distractions.
• Build the student’s self-esteem.

Resources

• National Institute of Mental Health. (2021). Attention-deficit/hyperactivity disorder in children and teens: What you need to know.

Bronchopulmonary Dysplasia

Bronchopulmonary dysplasia is a chronic lung disease, possibly related to oxygen toxicity or lung trauma from positive pressure ventilation in infancy, characterized by bronchiolar cell change and development of fibroid tissue to replace damaged lung tissue, known as metaplasia and interstitial fibrosis. Most infants suffering from this disorder recover near-normal lung function by age 1. Others require prolonged hospitalization, oxygen dependency, diuretics, digitalis, and chest physiotherapy. Right-heart failure and lung infections may result. For most students, long-term prognosis is excellent.

Recommended Guidelines

The school is responsible for obtaining a complete health history, medical records, and the provider’s treatment plan for the school environment. Medication and special health services will be administered by the School Nurse or in accordance with the guidelines for delegation of specialized health services. Students with a history of bronchopulmonary dysplasia are susceptible to lower respiratory infection, pneumonia, and symptoms of respiratory distress, including labored breathing and cyanosis. Every effort should be made to minimize exposure of the student to ill students or school personnel. Strict hand-washing procedures and sanitation practices should be observed in the classroom.

Cerebral Palsy

Cerebral palsy is a comprehensive term used to designate a group of non-progressive disorders resulting from malfunction of the motor centers and pathways of the brain. Although there are varying degrees and clinical manifestations of cerebral palsy, it is generally characterized by a movement disorder, paralysis, weakness, lack of coordination, and/or ataxia.

Spasticity refers to impaired motor activity because of disharmony of motor movements. Extremities may have an overextended or clenched appearance with rigidity. Athetosis is characterized by uncontrollable, jerky, irregular, twisting movements. Ataxia is characterized by an inability to achieve balance or awkwardness in maintaining balance, with associated gross and/or fine motor incoordination.

Recommended Guidelines

The school is responsible for obtaining a complete health history, medical records and reports, and recommendations for care in the school setting.

Specific areas of medical management that should be addressed in the Individualized Healthcare Plan include:

• Classroom safety measures.
• Health concerns such as seizures and respiratory needs.
• Nutritional needs.
• Exercise, muscle function, and bone health, coordinated with school physical and occupational therapists.
• Adaptive equipment.
• Lifting techniques and positioning.

Deaf and Hard of Hearing

Hard of hearing occurs when there is a hearing loss in speech frequencies over 20 decibels, and the loss of auditory acuity delays, inhibits, or prohibits the development of speech, language, and academic achievement.

Deafness refers to a hearing impairment so severe that the student is unable to learn primarily by the auditory channel, even with a hearing aid.

Conductive hearing loss refers to an impairment in the method of conducting sound waves to the cochlea of the ear because of blockage of sound waves by wax in the external ear, fluid behind the ear drum, damage or scarring of the ear drum, or dislocation or disturbance of the bones in the middle ear. It is usually medically treatable.

Sensorineural hearing loss refers to malfunction of the inner ear apparatus or eighth cranial nerve damage. It is medically irreversible.

Recommended Guidelines

The school is responsible for screening all students for hearing impairments and making appropriate referrals for complete hearing evaluations, obtaining a complete health history, and obtaining medical reports providing the provider’s recommendations for care in the school setting.

Ongoing medical management of the student’s hearing impairment should include the following and be addressed in the Individualized Healthcare Plan:

• Collaboration with audiologist to make educationally relevant recommendations.
• Care of hearing aids when indicated.
• Special education services available to the student should be explored.
• Culturally competent care for the hearing-impaired student.
• Encouragement of a multisensory approach to learning.
• Emotional support and referral to helpful community agencies should be provided as needed.

Safety concerns should be addressed in a written Individualized Healthcare Plan.

Diabetes Mellitus

Diabetes Mellitus encompasses a group of chronic metabolic conditions characterized by hyperglycemia/hypoglycemia resulting from defects in insulin secretion by the body, insulin utilization in the body, or both. Several pathogenic processes are involved as an individual is developing diabetes. These processes range from autoimmune destruction of the pancreatic beta cells that produce insulin deficiency to metabolic abnormalities that result in the body's resistance to insulin utilization.

Diabetes is one of the most common chronic diseases of childhood and is categorized as Type 1, formerly insulin-dependent or juvenile-onset diabetes, or Type 2, formerly adult-onset or non-insulin-dependent diabetes. Both types are seen in children and adolescents. Generally, individuals with Type 1 diabetes present with acute symptoms of polydipsia, polyphagia, polyuria, and weight loss. Once thought to be a disease of older individuals, Type 2 diabetes in children and adolescents has increased dramatically. Risk factors for developing Type 2 diabetes include overweight, family history of Type 2 diabetes, signs of insulin resistance such as acanthosis nigricans, female gender, and being of Hispanic, American Indian, Asian, or African American ethnicity. The onset of Type 2 can be less dramatic. As blood sugar and A1C levels become elevated, there is frequent history of polyuria, polydipsia, and occasionally weight loss with Type 2 diabetes.

NMAC § 6.12.11.8 outlines requirements for diabetes management in schools. It requires that a minimum of two school employees receive annual training in diabetes care. The training content for the annual diabetes training program, at a minimum, shall include:

• Identification and treatment of hyperglycemia and hypoglycemia.
• Appropriate actions to take when blood glucose levels are outside the target ranges as indicated by a student’s diabetes medical management plan.
• Understanding the interpretation of health care practitioner instructions regarding diabetes medication drug dosage, frequency, and manner of administration.
• Performance of finger-stick blood glucose testing and ketone testing, and recording of results.
• Administration of glucagon and insulin, and recording of results.
• Administration of glucagon and insulin through the insulin delivery system.
• Recognizing diabetes-related complications that require emergency assistance.
• Recommended schedules for food intake, and the effect of physical activity upon blood glucose levels.
• Appropriate actions to be implemented in the case of a schedule disruption.
• Recognition of hyperglycemia.
• Recognition of hypoglycemia.
• Actions to take in response to diabetes-related emergency situations.

The diabetes medical management plan is to be furnished by the parent or legal guardian of the student with diabetes. Any student who seeks diabetes care while at school shall submit a diabetes medical management plan to the school.

Any and all students diagnosed with diabetes, and who supply the school with a provider-completed medical management plan, shall receive appropriate and necessary diabetes care as specified in the student’s diabetes medical management plan.

In accordance with a student’s diabetes medical management plan, a School Nurse, or in the absence of a School Nurse, diabetes care personnel, shall perform diabetes care functions that may include:

• Checking and recording the student’s blood glucose or ketone levels and assisting the student with recording these levels.
• Responding to blood glucose levels that are outside of the student’s target range.
• Administering glucagon and other emergency treatments as prescribed.
• Administering insulin or assisting a student in administering insulin.
• Providing oral diabetes medications as prescribed.
• Following instructions regarding meals, snacks, and physical activity.

A School Nurse or at least one diabetes care personnel shall be at each school where a student with diabetes is attending and shall be available to provide care to each student with diabetes pursuant to this rule during regular school hours. All school-sponsored activities and trips; extended off-site, school-sponsored excursions; extracurricular activities where a student with diabetes is a participant; and bus trips on which the bus driver has not been trained in diabetes care, and a student with diabetes is a passenger, shall have a School Nurse or school personnel trained in diabetes care.

Students diagnosed with diabetes shall attend the school they would otherwise attend if they were not diagnosed with diabetes, and the diabetes care specified in the student’s diabetes medical management plan shall be provided at the student’s school.

Each governing body shall not restrict a student diagnosed with diabetes from attending any school on the basis of any of the following:

• The student is diagnosed with diabetes.
• The school does not have a full-time School Nurse.
• The school does not have trained diabetes care personnel.

A school shall not require nor compel parents or guardians to provide diabetes care for a student with diabetes at school or at school-related activities. Each governing body may allow a parent or guardian to volunteer to assume the official responsibility of diabetes care for a student diagnosed with diabetes should the parent or guardian be attending a school-sponsored activity, trip, extended off-site excursion, or extracurricular activity in which the student with diabetes is participating.

Upon written request of a parent or guardian of a student with diabetes and authorization by the student’s diabetes medical management plan, and upon demonstrated proficiency, a student shall be permitted to:

• Perform self-management blood glucose monitoring to check blood glucose and ketones.
• Administer prescribed medication for the treatment of diabetes including the self-administration of insulin through the insulin delivery system that the student uses, as determined in the student’s diabetes medical management plan.
• Treat hyperglycemia, as determined in the student’s medical management plan.
• Treat hypoglycemia, as determined in the student’s diabetes medical management plan.

A student with diabetes shall be permitted to self-manage in any area of the school or school grounds. A student with diabetes shall be permitted to always possess on the student’s person all necessary supplies and equipment to perform these monitoring and treatment functions.

If a student’s parent or guardian or the student requests, the student shall have access to a private area for performing diabetes care tasks.

Each governing body shall develop written policies or procedures to address safe storage of medical supplies and the safe and appropriate storage of diabetes medication.

A student with diabetes and the student’s parent or guardian may submit a written administrative complaint, via email or mail, to the secretary or secretary’s designee containing a statement of the facts on which the complaint is based, specific to any school or governing body that fails to meet its obligations to train school personnel to provide diabetes care, or to permit self-management of diabetes per the Student Diabetes Management Act.

Governing bodies shall submit this information no later than October 15 of the current school year, and every year thereafter, in a format required by the department for the preceding school year:

• The number of students within the school district or state charter school with a diagnosis of diabetes.
• The date(s) of the diabetes care training(s) provided to diabetes care personnel.
• The name(s) of the licensed School Nurse or licensed health care practitioner who provided the diabetes care training(s).
• A copy of the agenda for the diabetes care training(s).
• The name(s) and title(s) of each staff person identified as diabetes care personnel.
• The name(s) and title(s) of any other personnel who received the diabetes care training(s).
• The school(s) in which each identified diabetes care personnel provides services.

The department will post each district and state charter school report on the department’s website by November 15 of the current school year and every year thereafter.

Ongoing medical management of the student with diabetes may include the following and be addressed in the Individualized Healthcare Plan:

• Assessment and assistance of diabetes self-care, including monitoring of glucose highs and lows, and treatment as needed depending on the student’s level of independence and per medical provider recommendations.
• Education of students and staff of the signs and symptoms of high or low blood sugar, including:
  • Trembling or sweating.
  • Blurred vision.
  • Feeling weak or tired.
  • Sense of uneasiness or irritability.
  • Unable to think clearly.
• Encouragement and education of healthy lifestyle choices around diet and physical activity.

For students using insulin pumps, the School Nurse should verify the student’s competency to operate the pump and should assure that a backup system is in place should the pump needle become dislodged or the pump malfunction. The infusion site, usually in the abdomen, is moved every two to three days. Several different models of pumps exist.

Emotional support should be offered to students and parents by the School Nurse and staff, along with referral to appropriate community agencies as needed.

Depending on level of ability to self-treat, the diabetic student in New Mexico has the right to carry glucose monitoring equipment, routine self-treatment medications, and a quick-acting form of glucose to treat hypoglycemia.

Resources for Diabetes Training and Care Management

• DMMP sample fillable forms: DMMP and DMMP in Spanish.
• NMDOH Diabetes Training Resource Guidance.
• American Diabetes Association. (2020). Helping the student with diabetes succeed: A guide for school personnel.
• National Association of School Nurses. Diabetes care tools and technology.
• National Association of School Nurses. (2021). School nursing evidence-based clinical practice guideline: Students with Type I diabetes.
• New Mexico Public Education Department. Diabetes training.
• Wilt, L., & Jameson, B. (2021). School nursing evidence-based clinical practice guideline: Students with Type 1 diabetes. National Association for School Nurses.

Down Syndrome

Down Syndrome, also known as trisomy 21, is one of the most common chromosomal abnormalities in humans, occurring in approximately 1:800 live births. It is characterized by varying degrees of mental retardation and associated physical defects and difficulties. These include heart defects, frequent respiratory and ear infections, conductive hearing loss, low thyroid hormone levels, vision problems, and obesity. Atlantoaxial instability is present in 10–20% of these students. See the Atlantoaxial Subluxation section in this chapter.

Assessment of the student should include the following:

• Growth, charted on Down syndrome growth charts.
• Status and effects of any congenital abnormalities.
• Elimination patterns.
• Current treatment for thyroid dysfunction, if any.
• Auditory and visual acuity.
• Dental practices and concerns.
• Motor development.
• Cognitive development.
• Nutrition concerns.
• Orthopedic concerns.
• Immunization review. Pneumococcal, Hepatitis B, and influenza vaccines are strongly recommended.

Duchenne Muscular Dystrophy

Muscular dystrophies are a group of hereditary disorders characterized by progressive atrophy and weakness. Duchenne’s is a severe form of muscular dystrophy and affects predominantly boys. Difficulty in walking is apparent in early childhood, progressing to further muscle degeneration. Cardiomyopathy is a feature of this disease along with intellectual impairment. The degenerative changes including the fibrosis of muscle are a painless process. Death occurs around age 18, usually resulting from respiratory failure, intractable congestive heart failure, pneumonia, or aspiration/airway obstruction.

Eating Disorders

Anorexia nervosa is a disorder characterized by reduced body weight through caloric restriction when no actual loss of appetite occurs. The condition is marked by the determination to become as thin as possible, even in the face of life-threatening malnutrition. Bulimia refers to compulsive and recurrent binge eating of huge amounts of food. If it is accompanied by purging with vomiting or the use of laxatives, it is described as a syndrome and labeled bulimia nervosa.

It is recommended that the school:

• Assess the student’s current physical and nutritional status including weight/diet history, reproductive and menstrual information, and psycho-social and family history.
• Work with the student and other disciplines to form an optimal treatment approach.
• Monitor the student’s progress in dealing with eating behaviors and nutritional health.
• Refer the student for additional services as indicated.

It is important for the NMPED-licensed School Nurse to understand that a non-judgmental attitude is very important when interviewing a student regarding food issues.

Physical assessment of a student with an eating disorder may be perfectly normal since physical symptoms do not occur until later in the disease.

Heart Conditions

A congenital heart defect is a structural malformation of the heart or main blood vessels that is present at birth. It may be asymptomatic and benign or symptomatic and accompanied by such symptoms as cyanosis, respiratory problems, anorexia, poor growth, and/or fatigue. Some examples of congenital heart defects are pulmonic valvular stenosis, coarctation of the aorta, patent ductus arteriosus (PDA), atrial septal defect (ASD), ventricular septal defect (VSD), Tetralogy of Fallot, transposition of the great arteries, and tricuspid atresia. Congestive heart failure occurs when the cardiac output is inadequate to meet the metabolic demands of the body and results in accumulation of excessive blood volume in the pulmonary and/or systemic venous system. Pulmonary edema, or fluid in the lungs, and inadequate oxygenation may result. This is not common in children. Sudden cardiac arrest can occur in the event that a child has an undiagnosed congenital heart defect.

Observe for abnormal signs and symptoms such as:

• Exercise intolerance.
• Poor appetite or fatigue during eating.
• Dusky, mottled, or cyanotic skin, lips, mucous membranes, ear lobes, or nailbeds.
• Failure to thrive.

Monitor nutritional and fluid intake to assure adequate amounts are consumed to maintain growth and development. Practice proper procedures for preventing the spread of communicable diseases in the classroom. Every effort should be made to minimize close or prolonged exposure to ill students or school personnel.

Personnel working directly with the student may need to be certified in CPR.

Juvenile Rheumatoid Arthritis

Juvenile rheumatoid arthritis (JRA) is a childhood acquired autoimmune inflammatory disease with systemic involvement. Management of the disease is challenging due to its unpredictable and episodic periods of severe or acute exacerbations alternating with sudden remissions. The onset presents in three different forms: systemic onset, multijoint or polyarticular JRA, or onset in one to four joints, also called pauciarticular JRA. With any of these, remissions may extend from several months to years. During the acute phase, the student may experience pain and limited range of motion along with fever, fatigue, and stiffness. Children with JRA can have asymptomatic iritis, which can lead to blindness. Yearly evaluation by an ophthalmologist is recommended.

Students may require the following interventions depending on the phase, acute or non-acute, of the condition:

• Medication management to reduce inflammation and pain.
• Assistance with daily living activities including dressing, toileting, eating, carrying belongings, etc.
• Use of a brace or splint to support joints and prevent contractures.
• Physical or occupational therapy.
• Use of support systems such as assistive technology and adaptive PE.

The student’s involvement in their treatment and continual age-appropriate education regarding the disease is important. Including the student’s support systems is recommended.

School personnel should use a team effort to design activities that will achieve the educational goals and student success. It is recommended that students on aspirin therapy receive an influenza vaccine annually.

Healthcare providers monitoring children on aspirin therapy should be aware of the following information.

The FDA issued a final rule to amend its regulations to revise the Reye’s syndrome warning required for oral and rectal over-the-counter human products containing aspirin and to require a warning on over-the-counter drug products containing aspirin salicylates as active ingredients.

Kidneys or Urinary Tract Conditions

Urinary tract infection refers to an infection of the urethra, bladder, ureters, and/or kidneys, which may be caused by an organism or obstruction. Nephrosis refers to a degenerative disease characterized by edema and secretion of abnormal amounts of protein, fats, or albumin in the urine. Glomerulonephritis refers to inflammation of the kidneys caused by an antigen-antibody reaction following an infection. Congenital abnormalities of the urinary tract refer to abnormalities present at birth. They may or may not be correctable by surgery.

Hypospadias is one common abnormality in males and is characterized by malposition of the urethral opening. Ileal conduit, or ileoloop, is the anastomosis of one or more ureters to the ileum, or small intestine, which then serves to carry urine to the external body surface on the abdomen, where it is excreted into a collection bag.

Myelomeningocele / Spina Bifida

Myelomeningocele, also known as spina bifida, is a congenital malformation of the spine in which the posterior portion of the laminae of the vertebrae, or neural tube, fails to close, causing an opening through which the spinal cord and/or cord membranes, or meninges, protrude into a cyst filled with spinal fluid and covered with skin. It is usually surgically corrected in the neonatal period, but leaves the student with associated neurological, orthopedic, and urologic problems.

This can be manifested by development of hydrocephalus, loss of motor control and sensation below the level of the defect, muscle contractures, development of scoliosis, bladder incontinence and susceptibility to urinary tract infection stemming from incomplete emptying of the bladder, bowel incontinence, skin breakdown, overweight stemming from lack of activity, and possibly developmental problems. Recommendations include bowel and bladder management, diet, skin care, etc. It is recommended to complete a nursing assessment and develop an Individualized Healthcare Plan.

A multidisciplinary team approach to educational intervention involving the School Nurse, occupational and physical therapists, speech/language therapist, classroom teachers, and parents is recommended. Students may need the following interventions:

• Frequent diapering.
• Intermittent catheterization.
• Bowel management program.
• Special diet and assistance with feeding.
• Medications.
• Monitoring a V-P shunt if present.
• Monitoring prosthetic equipment.
• Addressing safety concerns including emergency evacuation.
• Special training in self-care.

Seizures

Epilepsy is a common neurological condition. It is the general term for more than 20 different types of seizure disorders. These seizures occur when there is a sudden, excessive electrical discharge within the cerebral cortex. The specific manifestations of the seizure are dependent upon the area of the cortex involved, as well as the rate and progression of the discharge.

Generalized Tonic-Clonic / Grand Mal

An aura may occur prior to the onset of seizure. Symptoms include loss of consciousness, sustained muscle contraction and rigidity of extremities and trunk, called tonic activity, that alternates with rhythmic jerking and flexor spasm of extremities, called clonic activity. Shallow breathing, suspended breathing, and incontinence of urine and/or stool may occur, which usually lasts a couple of minutes. Normal breathing then starts again. A postictal state may include deep sleep, disorientation, confusion, and short-term memory loss and last several hours.

Absence / Petit Mal

Absence is a brief lapse of awareness without loss of consciousness, lasting only a few seconds. The student has a blank stare, and minor motor movement may be present. The student may be unaware of the seizure and resume previous activities as if nothing happened.

Simple Partial

During a simple partial seizure, the student stays awake and aware with no loss of consciousness. Focal motor activity is present. Symptoms could include somatosensory symptoms such as headache, pins-and-needles sensation, or metallic taste; autonomic symptoms such as flushing, sweating, or salivation; and/or psychic symptoms such as experiencing a distorted environment or seeing or hearing things that are not there.

Complex Partial / Psychomotor or Temporal Lobe

The following symptoms may occur: impaired consciousness, repetitive automatic behavior, seeming dazed and mumbling, and actions that may be clumsy and not directed. The student may experience postictal confusion or sleep and have no memory of what happened during the seizure period.

Atonic / Drop Attacks

Atonic seizures involve a sudden loss of muscle tone or collapse. After ten seconds to one minute, the student can recover, regain consciousness, stand, and walk again.

Myoclonic

In a myoclonic seizure, the student may exhibit a brief bilateral flexor jerking of arms and dropping of the head. The legs may also be involved. There is usually no loss of consciousness.

Status Epilepticus

During status epilepticus, the student may exhibit a generalized Tonic-Clonic seizure lasting more than 15–20 minutes. An episode of repeated seizures that occurs without the student regaining consciousness between attacks, and which lasts longer than 30 minutes, is also considered status epilepticus.

Anoxic Seizures

Seizures severe enough to interfere with normal breathing and cause symptoms of total oxygen deprivation are called anoxic seizures. A prolonged seizure may result in cardiac arrest.

Seizures are sudden, basically unpredictable, and can be caused by a variety of factors. The following are factors that may trigger a seizure:

• Hormonal factors such as the menstrual period, puberty, and menopause.
• Non-sensory factors such as hyperthermia, hyperventilation, metabolic disorders, sleep deprivation, illness, and emotional and physical stress.
• Sensory factors such as those related to visual stimulation from flashing lights; auditory stimulation and startle reflex in response to sudden, loud noise; or touch or self-induced.

General Guidelines for Seizures

• The NMPED-licensed School Nurse is responsible for:
  • Obtaining a complete health history.
  • Obtaining medical reports providing the physician’s recommendations for care in the school setting.
  • Completing a nursing assessment and developing an Individualized Healthcare Plan.
• The NMPED-licensed School Nurse is responsible for monitoring the student with a seizure disorder. Any change in the behavior or mental state of the student observed by school staff should be reported to the School Nurse.
• Students who require seizure medication during the school day must have physician and parent/guardian authorization. This and any other specialized health service or precaution, including an Individualized Medical Emergency Plan, must be addressed in a written Individualized Health Management Plan.

Appropriate intervention with seizure activity in a student should be performed by the School Nurse or other school personnel who have been designated and trained by the NMPED-licensed School Nurse to follow procedures as directed by the School Nurse and Individualized Healthcare Plan.

Interventions to protect the student during a seizure include the following:

• If possible, ease the student to the floor or ground. Do not attempt to carry a student from the classroom or playground once a seizure has begun.
• Clear the area around the student.
• Do not restrain the student. If necessary, protect the student’s head and extremities from hitting hard objects or the floor by placing a folded blanket or your hand/arms under the student’s head, arms, or legs.
• Loosen clothing around student’s neck.
• Turn the student to one side or turn head to one side so that saliva or vomitus can flow out of the mouth.
• Do not attempt to place a padded tongue blade, gag, or fingers into the student’s mouth or force open clenched teeth.
• Remain with the student until movements stop and the student relaxes.
• Clean the student’s face, move to a more appropriate location if necessary, and change clothing if indicated.
• Allow the student to rest in a quiet area of the classroom. If the student has not sufficiently recovered in a reasonable length of time, the student should be sent home with adult supervision, preferably a parent/guardian.
• Continue to observe the student for reoccurrence of a seizure.
• Notify the School Nurse and parent/guardian of each seizure occurrence, according to the procedure established in the student’s Individualized Health Management Plan.
• Record seizure and all appropriate information on the student’s health room record.
• Provide emotional support to the student, family, classmates, and staff as needed.
• See Resources for sample documentation tools for seizures.

Guidelines for Anoxic Seizures or Status Epilepticus

• Implement the Individualized Medical Emergency Plan or Individualized Health Management Plan.
• Activate EMS for students with the following:
  • Seizure with respiratory compromise.
  • First-time seizure or no known prior seizure activity.
  • Seizure lasting longer than 5–10 minutes.
• Administer oxygen if indicated and previously ordered.
• Administer suction if indicated and previously ordered.

Resources for Training and Seizure Management in Schools

• American Academy of Pediatrics. (2021). Seizure management in schools.
• National Association of School Nurses. (2019). School nursing evidence-based practice clinical guideline: Students with seizures and epilepsy.
• National Center for Chronic Disease Prevention and Health Promotion. (2022). Epilepsy. Centers for Disease Control.
• Shafer, P. O. (2019). Schools and seizure preparedness. Epilepsy Foundation.

Thyroid Disorders

Hyperthyroidism

Hyperthyroidism is an endocrine disease resulting from an excessive secretion of the thyroid hormone and is frequently characterized by an enlarged thyroid gland, called a goiter, and prominent eyeballs, called exophthalmos. The condition may be treated surgically or with the administration of medication that blocks the production of the thyroid hormone. Undiagnosed hyperthyroidism can manifest as psychiatric disturbances before a student is diagnosed with hyperthyroidism. Monitor nutritional status to assure an adequate diet high in protein, calories, and vitamins.

Hypothyroidism

Hypothyroidism is an endocrine disease resulting from deficient production of thyroid hormone. It may be either congenital or acquired. Monitor nutritional status to assure a complete, well-balanced diet.

Traumatic Brain Injury

Traumatic brain injury (TBI) is any injury to the brain caused by an external physical force or by an internal occurrence, such as stroke, aneurysm, or brain infection, resulting in total or partial functional disability or psychosocial maladjustment. The term includes open or closed head injuries resulting in mild, moderate, or severe impairments in one or more areas, including cognition; language; memory; attention; reasoning; abstract thinking; judgment, problem-solving; sensory, perceptual, and motor abilities; psychosocial behavior; physical function; information processing; and speech. The term does not include brain injuries that are congenital or degenerative, or brain injuries induced by birth trauma.

The epidemiology of TBI in children and youth is staggering. The 15- to 24-year-old population sustains the greatest amount of injury, resulting primarily from motor vehicle accidents, falls, sports, and abuse. Many of these brain injuries are never diagnosed and rehabilitative services are never received. An unrecognized injury could result in a possible inappropriate educational placement.

The school is responsible for reviewing medical reports and for sharing relevant information with the educational team. Specific areas of medical management that may be addressed in an Individualized Healthcare Plan include:

• Screening for visual and auditory acuity and assisting in accommodation for visual or auditory deficits, if present.
• Monitoring for seizures.
• Monitoring shunt functioning.
• Administration of medication.
• Providing a safe environment and necessary accommodations.

A multidisciplinary team approach is required due to the complex needs evident with a brain injury and should be addressed in the Individualized Healthcare Plan.

Resources for Training and Care Management of TBI in Schools

• National Institute of Health. (2021). Traumatic Brain Injury resources.
• Centers for Disease Control and Prevention. Help children return to school after a TBI.

Visual Impairment

Impaired vision or blindness refers to insufficient or inadequate vision in varying degrees, which may prevent a student from being able to perform academic tasks or activities of daily living without significant modifications. Impaired vision may result from defective visual fields, decreased visual acuity, or impaired color vision. Students may be referred to as legally blind if they have a distance visual acuity of 20/200 or worse. Some students may have no vision or a small percentage of vision, or have only light perception.

Ongoing oversight of the student with visual impairment may include the following:

• Monitoring on a regular basis to assure that the student maintains the best possible correction and treatment of their vision problems.
• Assisting classroom personnel in interpreting the report of the student’s visual status.
• Making appropriate educational recommendations regarding the achievement of optimum visual efficiency in the classroom. This might include the following:
  • Seating the student in the front of the classroom, near the teacher and focus of instruction.
  • Placing the student in a well-lit area free from glare.
  • Presenting visual material with definite figure-ground contrast.
  • Presenting material in the student’s optimum field of vision.
• Exploring special education services available to the student and encouraging multisensory opportunities provided for the student to enhance learning and independence.
• Assuring the student is thoroughly oriented to the classroom, campus, and surroundings.

School professionals should use a team effort to design activities and experiences to achieve educational goals while providing for the safety of the student. The degree of supervision needed in each situation should be carefully evaluated and addressed in the Individualized Healthcare Plan, while providing emotional support and referrals to helpful community agencies as needed.

Resources for Impaired Vision

• Prevent Blindness. (2022). Vision and eye health. National Association of School Nurses with the National Center for Children's Vision and Eye Health.
• Prevent Blindness. (2012). Best practices and research: Children's vision and eye health — 12 components of a strong vision health system of care.