2012-2013 End of Year Report, Section 2
2012-2013End of Year Report, Section 2
School Health Nursing Survey and Program Summary
(Please use this worksheet to gather data about your LEA and complete one summary per school system or LEA. Please complete this form by June20, 2013.)
County
Name of LEA:
Total number of schools in this report:
School Population
Student Population
Total number of pre-kindergarten students served by school nurses:
Total number K-12 students. (Leave blank: This number will beprovided to DPH by NC DPI):
End of Year Staffing
Please update Form A with any changes that have occurred since Form A was completed in January and return to your Regional Consultant with Section Two.
Number of School Nurse positions that were vacant for more than six months during the 2012-2013school year.
Health Education Presentations/Programs
Number of times presentations were given by the school nurse for groups of students, parents, and/or school staff. Please include presentations given more than once.
Other than asthma, medication and first aid, what other health education topics were covered in group presentations given by the school nurse? Please check all that apply.
Alcohol and drug abuse
Tobacco
Allergies (other than medication training)
Blood Borne Pathogens (BBP - OSHA)
Cancer prevention (sun safety, other cancer prevention if not included in other categories)
Diabetes Management
Reproductive health (includes sex education, HIV/STD’s, puberty education, etc.)
Violence prevention (includes safe dating)
Dental health
Health careers
Infection prevention & control, other than STD, including handwashing,
flu prevention, immunizations, MRSA prevention
Pest prevention & control (pediculosis, mosquitoes, ticks)
Nutrition (including bone health, weight control, eating disorders)
Physical activity (including cardiac health)
Personal hygiene (if not covered under reproductive health)
Injury prevention (seatbelt safety, safe bicycling, helmet use, school bus safety, pedestrian safety)
Asthma Education and Care
Does your school have an asthma education program for staff? Yes No
Does your school have an asthma education program for students? Yes No
If yes, what curriculum is used?
Number of students in asthma education program taught by school nurse:
Number of students using peak flow meters per asthma plan:
Number of students using pulse oximeters per asthma plan:
Diabetes Education
Does your school/system offer annual generalized diabetes training to school staff, system-wide?
Yes No
Did your school/system have at least 2 staff persons who were intensively trained on diabetes care, in each school where students with diabetes are or were enrolled this school year? Yes No
First Aid
School nurses provide:
First aid classes Yes No
Certified CPR classes Yes No
First responders (a staff member identified as a point person in emergency vs. someone who handles first aid instead of/or in addition to the nurse)
Are available daily on each school campus? Yes No
Are available daily in each school building? Yes No
What agency trains first responders?
Other agency:
Use of Automated External Defibrillators (AEDs) in schools
Does your LEA have one or more AEDs in any of your school buildings? Yes No
How many times was one of those AEDs used this year on a: Student Staff Visitor?
What was the outcome of that usage? (If the AED was used multiple times, select all that apply.)
Survival Death (immediately or within 24 hours) Unknown
Home Visits
Number of home visits made by the School Nurses:
Reasons for home visits (please indicate all that apply):
Assessment Chronic illness Parent/family education
Absenteeism IHP development Other
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Identified Health Concerns Known to School Nurse
Please indicate the number of students in grade categories with the following identified health concerns:
Identified Health Concern / Elementary / Middle / HighPregnancy
Pregnant receiving homebound care
Dropped out of school due to pregnancy
Suicide attempt
Death from suicide
Suicide occurred at school
Death from homicide
Homicide occurred at school
Other student deaths (from injury, illness, etc.) regardless of location of death
How many student deaths from other causes occurred on school grounds?
Health Counseling
Please indicate the number of one-on-one health counseling sessions provided by the School Nurses on the following topics in each grade category. Do not include group presentations.
Topic / Elementary / Middle / HighADD/ADHD
Asthma
Child abuse/neglect
Chronic illness (not otherwise listed)
Depression (situational or chronic)
Diabetes
Hygiene
Mental health issues (not otherwise listed)
Nutrition
Pregnancy
Puberty; reproductive health
Seizure disorders
Severe allergies
Sickle cell
Substance abuse including tobacco use, prescription abuse, etc.
Suicidal ideation
Violence/bullying
Injury/illness that began or occurred outside of school
Outcomes forStudents with Chronic and/or Complex Health Care Needs
Please complete the following tables for ALL students with outcomes as a result of school nursing intervention this year.
Asthma Outcomes / Number of students for whom this was a measured outcome / Number of students demonstrating improvement in this outcomeA1. Consistently verbalized accurate knowledge of the pathophysiology of their condition
A2. Consistently demonstrated correct use of asthma inhaler and/or spacer
A3. Accurately listed his/her asthma triggers
A4. Remained within peak flow/pulse oximeter plan goals
A5. Improved amount and/or quality of regular physical activity
A6. Improved grades
A7. Decreased number of absences
Diabetes Outcomes / Number of students for whom this was a measured outcome / Number of students demonstrating improvement in this outcome
D1. Consistently verbalized an accurate knowledge of the pathophysiology of their condition
D2. Demonstrated improvement in the ability to correctly count carbohydrates
D3. Improved skill in testing own blood sugar.
D4. Showed improvement in HgA1C (if measured and available.)
D5. Consistently (90% of time) calculated insulin dose
D6. Improved ability to deliver insulin dose
D7. Improved grades
D8. Decreased number of absences
Weight Management Outcomes / Number of students for whom this was a measured outcome / Number of students
demonstrating improvement in this outcome
W1.Consistently verbalized accurate knowledge of relationship of food and activity to weight
W2. Kept a daily food diary as planned
W3. Increased physical activity (PE or after school)
W4. Improved frequency of healthy food choices
W5. Consistently able to identify appropriate portion sizes
W6. Improved BMI
W7. Improved grades
W8. Decreased number of absences
Seizure Disorder Outcomes / Number of students for whom this was a measured outcome / Number of students
demonstrating improvement in this outcome
SD1.Consistently verbalized accurate knowledge of the pathophysiology of his/her condition
SD2. Consistently recognized seizure triggers
SD3. Reduced side effects of seizure medications
SD4. Avoided complications from seizure activity
SD5. Reduced number of seizures
SD6. Improved grades
SD7. Decreased number of absences
Severe Allergy Outcomes / Number of students for whom this was a measured outcome / Number of students
demonstrating improvement in this outcome
SA1.Consistently verbalized accurate knowledge of the pathophysiology of his/her condition
SA2. Consistently avoided allergy triggers
SA3. Improved skill in recognizing hidden sources of allergen
SA4. Improved skill in epinephrine administration
SA5. Reduced episodes of severe allergic reactions
SA6. Improved grades
SA7. Decreased number of absences
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School Nurse Case Management Questions
Has your school health program incorporated a structured approach to school nurse management of students with chronic and/or complex health care needsas defined on page 7 of the Instructions? Yes No
If No, what do you think are the barriers to beginning a program? Please check all that apply.
Lack of data collection system or plan
Lack of someone to move a program forward
We don’t understand the value of a program
Locally high nurse/student ratio
If Yes, which of these components are included in your program? Please check all that apply.
Assessment with baseline health data
Assessment with baseline educational data
Identified health goals
Identified educational goals
Development of nursing care plan
Collaboration with health care providers and community resources
Collaboration with families (parents, siblings, extended family)
Documentation
Evaluation
How many totalstudents received structured case management by the school nurse(s) for students with chronic and/or complex health care needs this school year?
On average, when such management is provided, how often do the interventions occur?
Daily ___
2-3 times per week___
Weekly___
Every other week___
Monthly ___
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Student Medications
Number of students on long term medications (more than 3 weeks)Number of students on short term medications (less than 3 weeks)
Number of students on PRN (non-emergency) medications
Number of students on emergency medications
Out of number with emergency medications, # of students known to self-carry
Grade level of student / K-5 / 6-8 / 9-12
Epinephrine auto injectors
Diabetes medication
Asthma inhalers
How often were the following medications administered at school by these personnel?
Medication / Number of times administered by LPN / Number of times administered by RN / Number of times administered by other school personnelGlucagon
Diastat
Epinephrine
Versed
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Were any new medications given this school year (medications that had never been given in your LEA)? Yes No If yes, please list.
Has there been a need in your LEAto develop one or more corrective action plans in response to a medication error discovered during an audit at anytime this year?Yes No
If any, how many medication errors this year required the need for additional medical intervention?
How many physician-ordered Medical Diet Orders did a school nurse review or assist the Child Nutrition Program to implement?
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Injuries Occurring at School
Number of injuries / NumberInjuries occurring at school that resulted in permanent disability:
Type of disability:
Injuries occurring at school that resulted in death
Cause of death:
Injuries occurring at school that required law enforcement intervention (an injury that might lead to charges)
Types of Injuries/Incidents
Please indicate the numbers of injuries or incidents, not numbers of students, requiring EMS response or immediate care by a physician or dentist,and/orloss of ½ or more days of school.
Type of Injury or Incident / Bus / Hall / Classroom / Play
ground / Phys Ed / Shop / Rest
room / Lunch
room / Other location
Abdominal/Internal Injuries
Anaphylaxis
Back or Neck Injuries
Dental Injury
Drug Overdose
Eye Injuries
Fracture
Head Injuries
Heat Related Emergency
Laceration
Psychiatric Emergency
Respiratory Emergency
Seizure
Sprain or Strain
Other
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Identified Health Conditions
Total number of individualstudents with one or more chronic health conditions. _
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The following chart is also available in a formatted Excel chart, which will calculate your totals. Please indicate the number of students in each grade category with the following identified health conditions.
*An individual student may have dual/multiple diagnoses, so the total number of diagnoses will be larger than the total number of students with chronic health conditions. A care plan or 504 may not be necessary for each student.
Condition / Elementary / Middle / High / Number of related IHPs/plans of care / Number of related 504 plansADD/ADHD
Allergies (severe)
Asthma
Autistic disorders (ASD) including Asperger’s Syndrome, PDD
Blood disorders not listed elsewhere: (e.g. chronic anemia, Thalassemia)
Cancer, including leukemia
Cardiac condition
Cerebral Palsy
Chromosomal conditions not otherwise listed including Down’s Syndrome, Fragile X, Trisomy 18
Chronic encopresis
Chronic infectious diseases: including Toxoplasmosis, Cytomegalovirus, Hepatitis B, Hepatitis C, HIV, Syphilis, Tuberculosis
Cystic Fibrosis
Diabetes Type I
Diabetes Type II
Eating Disorders (including anorexia, bulimia)
Emotional/behavior and/or psychiatric disorder not otherwise listed
Fetal Alcohol Syndrome
Gastrointestinal disorders (Crohn’s, celiac disease, IBS, gluten intolerance, etc.)
Hearing loss
Hemophilia
Hydrocephalus
Hypertension
Hypo/Hyperthyroidism
Metabolic conditions or endocrine disorders not otherwise listed
Migraine headaches
Multiple Sclerosis
Muscular Dystrophy
Obesity (> 95th% BMI)
Orthopedic disability (permanent)
Other neurological condition not otherwise listed
Other neuromuscular condition not otherwise listed
Renal / Adrenal / Kidney condition including Addison's
Rheumatological conditions (including Lupus, JRA)
Seizure Disorder/Epilepsy
Sickle Cell Anemia
Sickle Cell Trait (only)
Spina Bifida (myelomeningocele)
Traumatic Brain Injury
Visually impaired (uncorrectable)
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List other identified health conditions not included above: _
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Health Care Procedures
Please indicate the number of students in each grade category who have orders for the following health care procedures at school.
Type of Procedure / Pre-K / Elementary / Middle / High / TotalBlood glucose monitoring
Clean intermittent catheterization
Central Venous Line monitoring
Diastat (Rectal Valium)
Epinephrine auto injector
Insulin injection
Insulin pump
Glucagon injection
Nebulizer treatment
Pulse oximeter
Respirator care
Shunt care
Tracheal suctioning (include tracheostomy care)
Stoma care (other than tracheal)
Tube feeding
Reinsertion of feeding tube
Vagal Nerve Stimulator
Other (total)
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List other health care procedures not included above:
Screening, Referrals and Secured Care- Refer to definitions
Please complete the attached Excel spreadsheet to indicate the number of PreK-12 students screened, referred and those who secured care by the School Nurses, school health staff, school personnel, or volunteers in each category at any time during the school year. Please email this spreadsheet to your Regional School Nurse Consultant along with this report.
School Health Advisory Council
Is at least one school nurse a regular member of your local School Health Advisory Council (SHAC)? Yes No
Is there a physician on your local School Health Advisory Council (SHAC)? Yes No
How many times did your SHAC meet during 2012-2013?
School Health Policies
Some state laws require school boards to enact policies to carry out the legislators’ directive. In a coordinated school health model, school health policies may impact each of the eight components of school health. The component of School Health Services impacts the school nurse’s role most directly. Please mark which of these topics have been addressed by your local Board of Education through written board approval.(See School Health Program Manual 2010 or 2012 editions, Section C, Chapter 2, for description of these policies.)
Medication administration
Prevention and control of communicable disease
Provision of emergency care
Screening, referral and follow-up
Maintenance of student health records
Maintenance of electronic health records
Special health care services (State Board of Education Policy GCS – G – 006)
Identification of students with acute or chronic health care needs/conditions (may be a separate policy or procedure for preceding policy)
Response to Do Not Resuscitate (DNR) directive
Reporting student injuries
Care of Students with Diabetes Act
Staff training on concussion awareness (Gfeller-Waller Concussion Act)
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Successes and Goals
Please describe the successes and accomplishments of your School Health Program for the 2012-2013 school-year. Include successes of your SHAC and other partners.______
Please describe any specific goals or objectives for your School Health Program for next year (2013-2014). ______
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Person preparing the report (only one per school system, please)
First Name:
Last Name:
Job Title:
Phone number, school-year:
Phone number, summer:
Email address (if more than one, list the one you would check during summer):
(Please complete this form by June20, 2013.)
Thank you!
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