Optimizing the Learning Environment

1. Optimizing the Learning Environment A Collaboration Between School Nurses, Physicians,and Families

2. What is the Nurse’s Role? • Facilitate positive student responses to normal development • Promote health and safety • Intervene with health problems • Provide case management services • Collaborate with to build a capacity for adaptation, self-management, self-advocacy, and learning. (NASN 2010)

3. How Is This Done During Illness? • Maximize student’s access to learning. Keep ‘em in school when they’re ready to learn. • Minimize children’s exposure to illness. Get ‘em outta there when they can’t learn. • Remain sensitive to families perception of illness and external demands. • Minimize impact on community health resources

4. Main Types of Transmission • Direct or indirect contact with infectious bodily fluids, skin lesions, blood, objects with infectious material (fomites) • Droplets with virus or bacteria coughed or sneezed reach a radius of about 3 feet • Strep, chickenpox, influenza, meningitis • Airborne – tiny infectious particles that spread rapidly and over distances • T.B., influenza, pertussis, SARS

5. Prevention of Infection • Wash your hands! • Proper hand washing • Soap and water is the best • Alcohol gel based soaps are convenient for class • Wash all exposed surfaces • Rinse well • Dry hands towel or air dry

6. Teaching Kids • Be an example. Kids learn from watching adults • Remind them when they need to wash • Show them how • The singing rule (Happy Birthday to You = 15 sec.; ABCs = 20-25 sec)

7. Teaching Kids • Covering coughs and sneezes • Tissue access in classroom • Use tissue first, elbow or sleeves next • Alcohol based soaps • Keep hands away from eyes, nose, or mouth

8. Should They Stay or Should They Go? • Do the child’s symptoms prevent him or her from comfortably engaging in school activities? • Does the child’s care prevent teachers from safely caring for other children in the class? • Could other children get seriously sick from close proximity? • School nurse guidelines also consider the emotional state of child with an illness

9. Special Considerations • Fevers treated differently in infants and toddlers • Unimmunized or underimmunized. Must take into account during VPD outbreak • Medically fragile: immune disorders, chronic steroid or immune modulating treatment, chronic lung disease, congenital heart disease, severe neurologic impairment • Communication disorders: autism, developmental delay, cerebral palsy

10. When Can They Return? • Symptoms are gone or much improved • They have been cleared as being non-infectious by a primary care provider, and • Their symptoms are not distracting or anxiety provoking, or emotionally upsetting to the child. • The child can participate in regular school activities without problems

11. School Notes • Parents come to me to ask for excuse to return to school or to be excused • Sometimes what the nurse or teacher sees is much different than parent’s expectations • In the office I have only parent’s account and perception of illness • Some illnesses evolve to become better or worse in a short period of time

12. School Exclusion • Most viral upper respiratory infections or mild enteritis are not infectious health concerns and should not be excluded for most students • Paroxysmal cough – pertussis? • Low grade fevers (oral temp <101) with common cold symptoms do not need to go • Higher fevers without any malaise, fatigue, or respiratory difficulty are often self-limited and may not need exclusion • One option is isolating child and rechecking temp in 30-60 min

13. School Exclusion: Pink Eye • Viral vs allergic vs bacterial • Viral: unilateral, less intense redness, minor discharge, school age kids • Allergic: seasonal, itchy symptoms, bilateral • Bacterial: bilateral, copious discharge, other symptoms (fever, respiratory illness, malaise) • Scant eye discharge of any color with no or minor eye redness – no exclusion necessary • If pink eye spreads to others then consider exclusion

14. School Exclusion: Diarrhea • Do not exclude: contained in diaper or child is continent • Frequency less than 2 stools “above normal” for the child • Blood or mucous in diarrhea may be infectious bacterial illness • Some special infectious require longer exclusion (ex- Shigella or Salmonella or E. coli)

15. Exclusion Criteria – Abdominal Pain • Vomiting more than twice in a 24 hour period unless it’s non-infectious and child hydrated • Bile or blood in emesis needs urgent attention • Abd pain is common and rarely infectious • If persists more than 2 hours or other symptoms then needs exclusion • Appendicitis signs: hungry child? jumping jacks? persistent worsening pain? • Observation usually gives the best info

16. Specific Exclusions • Lice – may remain until end of day then excluded until treatment done • Scabies – until first treatment done • Strep pharyngitis or scarlet fever – 24 hours after treatment started and fever free • Mouth sores with drooling until noninfectious • Rash with fever or behavioral changes • Other notables: chickenpox, measles, mumps, rubella, hepatitis A, pertussis, influenza • http://dhh.louisiana.gov/assets/oph/Center-PHCH/Center-CH/infectious-epi/Surveillance/sanitarycode.pdf • List of reportable diseases in Louisiana

17. Immunization Requirements • Age appropriate completion of: • Diphtheria, Tetanus, Pertussis (whooping cough) Haemophilusinfluenzaetype B (Hib), Hepatitis B, Measles, Mumps, Rubella (MMR), Polio, Rotavirus, Streptococcus pneumonia (pneumococcal), Varicella (chickenpox) • Encouraged but not required: Hepatitis A, Influenza, Meningococcal. • http://dhh.louisiana.gov/assets/oph/Center-PHCH/Center-PH/immunizations/Imm_Schedule.pdf • http://www.cdc.gov/vaccines/schedules/hcp/child-adolescent.html

18. Influenza • Influenza caused by multiple strains of influenza virus. Different strains are not important except for the unknowns may cause pandemic influenza. • Prominent symptoms: fevers (usually high), cough, runny nose, sore throat, chills, aches • Quick onset of symptoms • Brief incubation period: 1-4 days

19. Influenza • Flu itself may cause severe disease or a secondary infection may occur. • Childhood deaths since national reporting in 2004: range from 46 (2005-6) to 344 (2009-10). Laboratory confirmed cases. Half had no at risk conditions. • Most vulnerable are very young or elderly or those with chronic lung disease or immune deficiency. • Not a reportable disease, but be very aware of special needs or immune compromised children who are exposed. They may need prophylaxis.

20. Pertussis (whooping cough) • Causes a prolonged coughing illness for weeks to months. Most school age kids not in danger. • Most severe cases in unimmunized children less than 6 months old • Severe cough with gagging, coughing, low heart rate, and apnea • Coughing in infants can cause subdural bleeds, hernias, and seizures • Hospitalization in 2 of 3 infants and mortality of 1% in unimmunized 2 month olds

21. Pertussis • Incidence is on the rise. 33,000 cases reported to the CDC in 2014 (15% rise from 2013) • Acellular vaccine is safer but has waning immunity so it’s important to keep up with boosters. • Spread by airborne droplets. Incubation period is wide range (5 – 21 days) • Close contacts are those who have been within three feet or in confined spaces with the sick child. Must be watched carefully for development of symptoms within 21 days • Parents and care givers should be notified of exposure and seek medical evaluation. Reportable disease

22. Pertussis • Children and teachers with pertussis need exclusion from school until they’ve completed the antibiotic course (azithromycin for 5 days) • The cough is no longer infectious after the antibiotic is done, but must take into consideration the learning environment • Any contact who starts with symptoms of upper respiratory illness within 21 days of exposure should be excluded until they’ve seen their doctor and taken the antibiotics

23. Varicella • “Dew-drop on a rose petal” • Lesions progress in various stages: red spot to vesicle to small scab. • May have low grade fever and malaise • Can be complicated by skin infections, pneumonia, or brain/nerve involvement. • More severe in infants, adolescents, and adults. Can be deadly to immune compromised • Never use aspirin in children due to Reye syndrome association

24. Varicella and pregnancy • Congenital infection can occur if pregnant mothers are infected in the first or second trimester • May develop brain and limb malformations • Newborns who get chickenpox from their mother just before birth have a high mortality rate.

25. Epidemilology • Humans are the only source of infection • Transmitted from sick person with chickenpox vesicles via airborne droplets. Very contagious • Incubation from 10 – 21 days • Virus unable to survive long in the environment • Immunity from vaccine tends to be lifelong • Contagious from 1 to 2 days before rash until all lesions have crusted over

26. Zoster (shingles) • Results from a reactivation of dormant chickenpox in the nerves • Causes a cluster of red, painful blisters in limited areas of skin usually on one side • Usually has a painful or burning sensation • Post herpetic neuralgia can last for weeks • May rarely occur after varicella immunization • Contact transmission with open sores

27. Child Care/ School • May return when the rash has crusted over • Only need to exclude zoster if the lesions can’t be covered. • Exposed susceptible people may be treated with vaccine or immune globulin products • Notify parents of exposure • Identify susceptible kids or teachers • Counsel them to seek care • Monitor for development of s/s from day 8-21

28. The Nurse’s Office 12 year old female student comes to your office with 102 fever, muscle aches, and head ache. She is alert and talkative but looks uncomfortable. She has this rash. What to do?

29. Meningococcal Disease • Onset usually abrupt with high fevers, aches, chills, malaise, lethargy, but may be non-specific and gradual buildup • Rash can be indistinguishable from other common viral rashes • About half of infections result in meningitis • 30-40% in blood infection • 10-15% mortality rate & up to 20% chance of severe complications (disability, limb amputation, hearing loss, etc)

30. Meningococcal Disease • Person to person spread through droplets. Some people are asymptomatic carriers. • Requires prophylactic antibiotics for close contacts regardless of immunization status • Reportable disease • Infection control extremely important

31. A Rash In the Class • Low grade fevers, drooling, painful sores in mouth, blisters on hands in a first grader

32. A Rash In the Class • Hand, Foot, and Mouth Disease caused by enterovirus. • Spread by fecal-oral route and may survive on contacted objects for transmission • Best way to prevent spread is hand washing and cleaning surfaces • Child exclusion until blisters healed up and no fevers

33. A Rash In the Class • 7th grader without any other symptoms developed this rash after lunch. He was absent yester day with an illness but his parents said he was all better this morning without fevers. Is it an illness or allergy? Does he need to go home?

34. Erythema Infectiosum • “Slapped-cheek disease” caused by Parvovirus B19 • May start with mild infectious symptoms but not always • When rash occurs, it’s no longer infectious • Exposed pregnant women should notify their obstetrician

35. A Rash In the Class • Low fevers, sore throat, decreased energy and appetite in a 4th grader. • What is this rash called? • Does he need to see his doctor? • When can he return?

36. Scarlet Fever • Streptococcal pharyngitis with scarlet fever • Needs school exclusion asap. • May potentially return after treatment and when fever free.

37. A Rash In the Class • High fevers, malaise, conjunctivitis, sore throat with red spots, cough sudden onset in kindergartener with unknown immunization status. What is the likely diagnosis? Should this be reported?

38. Measles • Needs immediate removal from class and notification of parents and healthcare professionals and/or DHH • Check immunization status of all children in the classroom and teachers • Post exposure prophylaxis may be indicated for close contacts • Very infectious and case fatality rate of 1-3 per 1000 infections

39. Summary • School nurses play a vital role in the teaching environment • Caring for the well being of children so learning can be optimized • Protecting others from spreading infection • Communicating with parents and health professionals to prevent and treat severe illness • Thank you for having me!!!