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Screening Techniques for the School Nurse

Screening Techniques for the School Nurse. Introduction to School Nursing. Screening Programs.

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Screening Techniques for the School Nurse

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  1. Screening Techniques for the School Nurse Introduction to School Nursing

  2. Screening Programs • 704 KAR 4:020(2)(11), The Board of Education shall adopt a program of continuous health supervision for all enrollees. Supervision shall include scheduled, appropriate screening tests for vision, hearing and scoliosis. • Only scoliosis is mandated in this regulation to be performed at grades six (6) & eight (8). The specific scheduling (grades) of vision & hearing is at the local district’s discretion.

  3. Visual Acuity • Screening for distance is the single most important test of visual ability • Has educational significance due to the relationship to learning • 20/20 is considered normal vision

  4. Vision Screening • 1 in 20 preschoolers has a vision problem • Undetected & uncorrected vision problems can lead to serious difficulties for a child • Children are often unaware of their vision problem • 85% of amblyopia cases are not detected until after the preschool years • Detect & prevent serious lifelong & irreversible vision problems

  5. Common Eye Problems:Myopia (nearsightedness) • Inability to see distant objects • Thought to be hereditary • The most common refractive error affecting 1% of 6 year olds • In infancy can be more severe than in school-age children • Tends to worsen with age

  6. Strabismus • Results from eye muscles not working together • Difficult to detect-may be constant, come & go, or alternate from one eye to the other • One may remain straight & then the other eye turn slightly inward, may score 20/20 on the eye chart • Affects 3-5% of children • If uncorrected, strabismus can result in amblyopia (loss of vision)

  7. Amblyopia (Lazy Eye) • Reduced visual acuity in an eye (lazy eye), not adequately used during early childhood (often caused by strabismus) • Is NOT OBSERVABLE; must screen both eyes to find this condition • Affects 2-5% of general population • If untreated by age 6, permanent vision loss is likely • Treatment involves patching the good yet to re-train the brain to accept images from the affected eye

  8. Other Vision Defects • Astigmatism-light cannot focus clearly on the retina, often causing blurred vision • Hyperopia- farsightedness; inability to focus on nearby objects

  9. Appearance Signs • eye redness or discharge • swelling/crusting of the eyelids • Haziness or clouding of the eye • eye crossing or misalignment (strabismus) • Eyes “jiggle” (nystagmus) • Protruding eyes (proptosis) • Drooping eyelids (ptosis) • Alignment of the eyes • Non-round pupils/pupil size

  10. Behavior Signs • Constant heat tilt or face turn • Squinting • Rubbing eyes excessively • Closing or covering one eye • Holding objects close to the eyes • Blinking excessively

  11. Compliant Signs • Headaches • Blurry vision • Double vision • Eyes itch, burn or feel scratchy • Unusual sensitivity to light

  12. Vision Assessment • Vision acuity is assessed in the school age child by the Snellen or Sloan chart or a vision instrument tester (Titmis/OPTEC 2000) • Same procedure for both eyes • Begin testing with the line above the referral line & test down • If student wears glasses, test with glasses

  13. Supplies for the Chart Test • Eye chart • Window card • Tape measure • Adequate lighting • INDIVIDUAL eye covers (may be made with construction paper with rounded corners or paper cups) to prevent the spread of infections

  14. Prepare the Screening Area • Select location that is quiet & free from distractions • Select location that has good lighting & light colored walls with no glare or shadows • Attach the chart to wall, with the passing line at the student’s eye level • Mark exactly 20 feet ( or 10, according to chart used) of distance from chart • Cover upper & lower portion of the chart with cover cards

  15. Prepare the Child • Show the child the large letter E/symbols so he/she is familiar • Place the child in a standing position at the 20ft/10ft mark, facing the chart (a set of footprints affixed to the floor with the heels at the 20/10-foot mark may help keep the child with proper position • Teach the child to have both eyes open during the test (when covering either eye)

  16. Procedure • Test both eyes first, then the right & left • Test with glasses if applicable • When testing one eye, occlude the other eye • Begin on the 50-foot line of the chart for 3,4, & 5 year olds. If the line is read correctly, proceed to the 40-ft line • Begin on the 40-foot line of the chart for all students above 6 years of age. If the line is read correctly, proceed to the 30-ft line • With upper & lower portions of the chart covered, expose one symbol at a time

  17. Move window card according to the speed of the student • In linear testing, it may be necessary to use a pointer to indicate the letter • Student point with his/her arm/hand in the direction of the legs of the “E” point • To pass, the student must see one-half or more than half of the symbols on that line • Observe for eye problems (tilting of the head or peeking) • Record visual acuity (the last successful line read, both eyes, right and left eye)

  18. Documentation • Record the results as a fraction-i.e.,20/30, 20/40 • The numerator represents the distance from the chart • The denominator represents the last line read • A reading of 20/50 indicates that the child read at 20-feet, the line that should be read at a distance of 50-feet • The larger the denominator, the poorer the vision • When using a vision instrument tester, follow manufacture’s direction • Record screening results on flow sheets, cumulative/individual health record & other appropriate records/documents

  19. Referral Criteria-Ages 3-5 • Refer if visual acuity is poorer than 20/40 in both or either eye • Refer if there is a two line difference between the eyes even in passing range (i.e. 20/25, 20/40) • Refer if possible signs of visual disturbance are present

  20. Referral Criteria for Ages 6-Adult • Refer if visual acuity is poorer than 20/30 in both or either eyes • Refer if there is a two line difference between the eyes even in the passing range (i.e. 20/20, 20/30) • Refer if possible signs of visual disturbance are present • Avoid using the word fail in front of the student or parent

  21. August 2008 • In accordance with KRS 200.703, Early Childhood Development, all children enrolling in the Kentucky School System must have a vision examination by an Optometrist or Ophthalmologist before entering school.

  22. Hearing Screen • Identifies children with hearing impairment • Aids in the teaching & prevention of hearing loss • Aids in planning for medical referral, treatment and educational programs • Five to ten percent of school age children do not pass audiometric tests • Approximately 2 % of children will show permanent hearing impairment and require special educational services

  23. Effects of Hearing Loss • Interference with normal speech & language development • Development of abnormal social growth & behavior • Interference with education & human potential • Development of adjustment problems in the child & his/her family • Isolation in a hearing world

  24. Hearing • Measured in decibels (loudness) • Normal speech is 50-70 decibels, (refrigerator is 40, screaming child is 90 and a jet taking off is 130) • Sound also has pitch, high or low sounds, which is measured in Hertz • Hertz- is the frequency/number of cycles per second of pure tone • Low tone would be 250 Hertz or the sound of a bullfrog; high tone would be 4000 as a whistling tea kettle • Threshold- is the softest level at which one hears the frequencies

  25. Hearing Disorders • 1. Sensorineural-permanent losses results from inner ear defect, auditory nerve damage, damage to the auditory center in the temporal lobe of the brain • Causes- viral (especially measles & mumps), bacterial infections, prolonged exposure to loud noises, congenital abnormality & head trauma • Treatment- hearing aids, speech therapy (lip reading)

  26. 2. Conductive – not permanent & is the most common loss in children, results from problems in the external ear canal, tympanic membrane, or middle ear cavity, interferes with sound transmission, may be mild or severe • Causes- impacted earwax, foreign objects (beans, erasers, cotton), otitis media, congenital abnormalities and ruptured/scarred eardrums • Treatment-Many cases respond to medical or surgical therapies, losses may fluctuate over time • Possible to have a conductive & sensorineural hearing loss at the same time

  27. Effects of Hearing Loss • Mild hearing loss (15-30db)-difficulty hearing faint or distant speech, may use hearing aid, needs preferential seating • Moderate hearing loss (30-50db)- difficulty hearing distant speech, requires amplification, preferential seating, auditory training, probable speech therapy (hard of hearing)

  28. Moderate-Severe (50-70db) – difficult with conversation unless loud; difficulty in group/classroom discussion; requires hearing aid; may require special class for hard of hearing • Severe/deaf (70-90)- May hear loud voice close to ear; hear some vowels, recognize environmental sounds, special education for the deaf & with speech language • Profound deaf (over 90db)- May hear loud sounds, does not rely on hearing for communication; requires special education for the deaf

  29. Testing • Hearing is assessed in children 3 years and older (depending on understanding & cooperativeness), adolescents and adults with pure tone screening (audiometers) • The room should be as quiet as possible • Tester may test him/herself to be sure the noise level in the room will not interfere with the testing • The room should be large enough to accommodate a table, the audiometer and chairs for the tester and student • Student chair’s should be positioned so the student cannot see the operation of the audiometer.

  30. Pure Tone Screening Procedure • Turn the audiometer on • Check to make sure masking is turned off • Output selector: Red earphone on the right ear, blue earphone on the left ear • The following test levels shall be followed for these frequencies:

  31. A. 1000 Hz 2000Hz 4000Hz • B. 20 dB for sound proof room • C. 25 dB for exam room • Give verbal instructions for student to raise their hand when a tone is heard • For children 6 and below more often may hand or drop a block when a tone is heard • Without wearing the headset, demonstrate by turning the tone to 90dB and raise your hand when you hear the tone

  32. Screening • Set frequency dial to 1000Hz • Set hearing level at 20dB • Present the tone by pressing the tone level (to be assured the student is responding correctly, the tone may need to be presented several times) • Once a desired response is received, continue the test as follows:

  33. Exam Room Area • Test right ear at 1000, 2000, 4000Hz at 25 dB • Test Left ear at 1000, 2000, 4000 Hz at 25 dB • If patient does not respond to the first tone in the right ear & the first tone in the right ear at 1000 Hz:

  34. A. Increase the hearing level to 30dB (leave on right ear at 1000) • B. If no response increase to 40dB • C. If no response increase to 50 dB • D. If not response, switch the control to the left ear and follow the same procedure, increase by 10db, decrease by 5dB *NEVER GO ABOVE 50 dB*

  35. Sound Proof Room • 1. Test right ear at 1000, 2000, & 4000 Hz at 20dB • 2. Test left ear at 1000, 2000, & 4000 Hz at 20dB

  36. Pass/Fail Criteria • Screening test is failed is the student fail to hear any one tone, in either ear • A re-screening should be administered in two weeks for the student, if the student fails a second screening, he/she should be referred for proper follow-up • Document results on the appropriate forms

  37. Audiometer Screening Pointers • If unable to obtain a rapid response, temporarily fail and retest later • Present tones only at the screening levels • Do not go higher than 50 dB with an unsuccessful student • Do let the student see the tester operate the tone level switch • Do not look up each time a different tone is presented

  38. As a general rule it is better not to indicate that a response is correct or incorrect to the student • Do not require the student to raise the hand that corresponds to the ear that the tone is heard in • The success of the screening depends on the skills of the tester, the testing area, and the function of the audiometric equipment

  39. Pupils difficult to test: • An ear examination using an otoscope by a physician, nurse practitioner or school audiologist is indicated • Teacher input regarding the student’s classroom performance is needed • Gross testing procedures such as alerting (eye movement, head turn, facial expression), noise makers (finger snap, hand clap) when presented at varying loudness & distance may be useful • Parent input regarding past history, auditory awareness and responsiveness to sounds in the home environment • Referral to outside agency (i.e. Commission for Children with Special Needs)

  40. Audiometer • Check the audiometer and headphones for proper functioning in the room where the screening will be done • Calibration and any needed repairs should be done annually. After each calibration the dealer/lab should provide a Certificate of Calibration

  41. Body Mass Index-BMI • CDC-Centers for Disease Control & Prevention produced the Body Mass Index as a screening tool to determine obesity & those at risk for weight-related health problems • BMI- can be plotted for children after age 2 • BMI-the ratio of weight to height squared • Height & weight screening is used to identify children who may be at risk for abnormal growth patterns for their age, weight and/or heredity • No mandated KY law for screening height & weight (district may set policies requiring these screenings) • KDE suggests these screening measured annually in preschool & elementary; one time during middle and high school

  42. 1980-2004 the percentage of obese youth tripled from 7% to 19% in children (6-11 Years); 5%-17% in adolescents (12-19 years) • BMI in schools aids in surveillance & screening purposes

  43. Obesity Impact • Heart Disease, caused by high cholesterol and/or high blood pressure • Type 2 diabetes • Asthma • Social discrimination • Sleep apnea

  44. Measurement Procedures Height Essential that a quality meter is used, whether permanently fixed to the wall or portable (preferred installed with a level to the wall) Student should stand with head, shoulder blades, buttocks & heels touching the wall, wearing only socks or bare foot Knees are straight and feet flat on the floor while student looks straight ahead The moveable headboard is lowered until it touches the crown of the head, compressing the hair Height is recorded to the nearest 1 cm or ¼ inch Read & plot measurement on age & gender specific growth chart and evaluate accordingly *Height attachments on beam balance scales should never be used to measure height

  45. Measurement Procedure for Weight • Balance beam or digital scales (* all scales should be zero balanced & calibrated annually according to manufacturer’s instructions) • Weigh student after removing outer clothing & shoes (minimal clothing) • Place student on the middle of the scale • Weight is recorded to the nearest 0.1 kg or ¼ pound • Read & plot measurements on age & gender specific growth charts and evaluate accordingly • Do not use bathroom or spring balance scales • Always provide privacy

  46. Once the BMI is determined, student’s age & gender are used to select the appropriate growth charts (BMI for age) • Find the student’s age on the horizontal axis & the BMI value on the vertical axis to determine the BMI for age percentile

  47. BMI For Age Percentile Categories • Overweight- BMI for age percentile > 95th • At risk for overweight- BMI for age between 85th & 94th percentile • Normal range- BMI for age between 5th & 84th percentile • Underweight – BMI for age < 5th percentile

  48. Communication • Handle results in a sensitive manner, non-judgmental use factual approach in providing education & interventions (i.e.-a healthy diet, exercise or referral to PMD to rule out a medical problem • Give parents copies of information to take home and digest later in privacy • If information is mailed home, follow-up with a personal contact (if possible) • * Always check with local school/district policy before disseminating information

  49. BMI • BMI age-for-growth charts can be used with children/adolescents ages 2-20 years • Download growth charts on the CDC web site: http://www.cdc.gov/growthcharts • Determine BMI value by plotting the height & weight measures on CDC tables • CDC tables list measures in both metric & English; do not require mathematical calculations • BMI wheels may also be used (align height & weight on wheel; are inexpensive) • CDC provides an online calculator to determine BMI at http://www.cdc.gov/nccdphp/dnpa/growthcharts/bmi_tools.htm by entering the height & weight measurements

  50. Web Sites • www.cdc.gov/Features/ChildBMI/ • www.cdc.gov/healthyyouth/obesity/bmi • www.apps.nccd.cdc.gov/dnpabmi/ • www.cdc.gov/healthyweight/assessing/bmi/childrens_BMI/tool_for_schools.html • www.shapeup.org/oap/entry.php

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