The Role of the School Nurse

* The Role of the School Nurse

* *Neurology Screenings should be completed for: *Initial Special Education Testing *Out-of-State Transfers *Re-evaluations/In-State Transfers with Neurological Concerns or History *Annual Updates with Neurological Concerns or History *Students who will be Referred to the Neurology, Medical Consultant or Genetic Clinics

* Indicators of Possible Neurological Issues and Need for Further Review *Health/Developmental History Review form *Social/Behavioral History Review form *Health Known health problems, medications, limits on activities * Cerebral Function Orientation, reasoning, judgment, attention, behavior *Appearance facial shape, symmetry, size, skin markings, hygiene, etc. *Growth Parameters Ht, Wt, BMI and head circumference with percentages *Vital Signs Pulse, blood pressure, resp rate * Eyes Vision screening, misalignments, unusual findings *Ears Hearing screening, otoscopic exam, unusual findings *Nasal/Oral Nose, lips, tongue, mouth, dental *Fine Motor Hand dominance, handwriting, functional skills *Gross Motor Balance, functional skills *Spine/Back Curvature, asymmetry

* BRAIN FUNCTION AND MAP: http://www.neuroskills.com/brain.shtml

* *Hard vs Soft Neurological Signs *Cerebral Function *Cerebellar *Hand Dominance/Handwriting *Finger Opposition (Finger to Thumb) *Eyes Open/closed touch finger to nose *Figure of Eight *Heel to Shin Test *Muscle Size, Tone and Strength *Pronate and Supinate Hands *Pronator Drift *Tandem Walking *Walks Naturally with Eyes Open *Walks Naturally with Eyes Closed *Ambulate Toes and Heels *Toe-Walking / Heel Walking *Balance *Hop, Jump, Skip *Floor to Stand *Romberg s Sign

*Hard Signs *Obvious indications of nerve or brain damage *Pathological reflexes, abnormal EEGs, abnormal audiograms, unilateral movement disturbances, loss of function of one or more cranial nerves *Objective and reproducible *Soft Signs *Slight abnormalities of behavior during neuro exam *Speech disturbances, awkward gait, hyperactivity, poor balance, lack of coordination, low muscle tone, posturing, tremors

*Cerebral Function: *Appearance *Orientation to person, place, time *Level of consciousness *Behavior *Ability to complete age appropriate tasks *Speech, language *Judgment, reasoning, memory, attention skills *Affect, mood, social skills *Cerebellar: *Posture *Coordination *Balance

*Sample of student s handwriting *Which hand is dominant *Note if pencil grasp is efficient or not efficient * Efficient: * Not efficient *Assess ability to button, tie shoes, zip, feed self, open/close containers, pick up small objects

*Finger Opposition (Finger to Thumb) for 6yrs and older *Normal 5-8 yrs easy transition, may put same finger on thumb several times *Normal 8-10 yrs easy transition, smooth placing of fingers *Abnormal asymmetries or associated movements, tremors

*Eyes open Touch finger to nose *Normal 7-8 yrs old may miss finger once or twice or slight wavering of moving hand *Abnormal asymmetries, tremors *Eyes closed Touch finger to nose *Normal 8 yrs and older correct placement of finger and smooth *Abnormal asymmetries, tremors *Figure of Eight *Draw a figure 8 prior to testing *Draw a figure 8 in the air with each foot *Looking for smooth effort

*Heel to Shin Test *Place heel of one foot under knee of opposite leg and move foot down slowly *Fails if unable to place heel on shin or must assist the heel with the hands *Muscle Size, Tone & Strength *Note symmetry of muscle mass *Test range of motion *Note resistance, rigidity, hypotonia, flaccidity, paralysis or atrophy *Test flexion and extension of arms and legs with resistance

*Pronate & Supinate Hand (Alternate Hand) *Normal 4-7 yrs awkward pronation and supination with associated movements noted in opposite extremity, gradual improvement *Normal 8 & over smooth, possible minimal movements in opposite extremity *Abnormal asymmetries and directional confusion *Pronator Drift *Observe posture as child stands with eyes closed and arms straight out with palms down, then turn palms up with eyes remaining closed * Normal able to maintain balance * Abnormal arm drift, swaying, finger flexion, asymmetric pronation

*Tandem Walking 5 yrs and older *Walk 8 steps on line forward and back with heel touching opposite toe *Normal 5-7 yrs 3 deviations are acceptable *Normal 7 yrs and older able to walk 4 steps in line 2 out of 3Xs *Abnormal unable to complete 4 sequential steps *Walking Naturally with Eyes Open and Eyes Closed *Observe posture, head, swinging of arms, size of steps, alternate feet *Normal smooth movements, alternating feet *Abnormal wide gait, tripping, swaying, toe walking, limp, leg preference, drags foot, need for assistive devices

*Toe Walking 20 Continuous Steps *Normal 3-7yrs can walk on toes with decreasing associated movements *Normal 7yrs and older can walk on toes with no associated movements *Heel Walking 20 Continuous Steps *Normal 3-9yrs can walk on toes with decreasing associated movements *Normal 7yrs and older - can walk on toes with no associated movements *Abnormal note inability to perform as noted above *Walk on Outside of Feet (Additional Option not in Manual Sec H) *Balance Test Each Foot Separately *Normal 3-5yrs -stand 5-6 sec with many extraneous balancing movements *Normal 5-6yrs -stand 10-12 sec with many extraneous balancing movements *Normal 6-7yrs stand 13-16 sec with min extraneous balancing movements *Normal 7 & up stand 20 sec with no extraneous balancing movements * Abnormal asymmetries, associated movements

*Hop *Normal 3-4yrs few are able to hop even a few times *Normal 4-5yrs can hop 5-8 times consecutively *Normal 5-6yrs can hop 9-12 times consecutively *Normal 6-7yrs can hop 13-16 times consecutively *Normal 7 & up can hop 20 times consecutively with each foot * Abnormal inability to hop, weakness, ataxia *Jump *Normal age 2 ½ able to jump with both feet off floor *Normal by age 3 able to jump over piece of paper on floor *Abnormal inability to perform as above *Skip *Normal rhythmic skipping by age 6 *Abnormal gallop after age 6, inability to sequence skips

*Floor to Stand *Normal able to stand from a seated position on floor without hands *Abnormal uses hands to walk up body from squatting position (Gower s Sign), note calf muscle weakness, loss of tone *Romberg s Sign *Student stands with feet together, eyes open and hands by sides *Examiner stands to side of student with one hand in front and one hand in back of student without touching *Observe for swaying or movement *Repeat with student s eyes closed *Abnormal Student sways, falls or is unable to balance without wide based foot placement. If positive, postpone other cerebellar testing that requires balance

*OLFACTORY (I) * *With eyes closed, child should be able to identify familiar odors *Not required as part of health assessment *OPTIC (II) *Visual acuity within normal limits *OCULOMOTOR (III) *Observe tracking, inspect pupils for size, shape, reaction to light, accommodation of far and near objects, inspect eyelids *TROCHLEAR (IV) *If abnormal, the child will be unable to look downward and eye at rest may deviate upward *TRIGEMINAL (V) *No disparity of tension when palpating the masseter muscles with fingertips while child clenches teeth

*ABDUCENS (VI) *If abnormal, child cannot look temporally and eye at rest may deviate basally *Most frequently involved nerve when brain damage is present *FACIAL (VII) *Mouth should be symmetrical bilaterally when child smiles *AUDITORY (VIII) *Should be able to hear normally *GLOSSOPHARYNGEAL (IX) *When posterior pharynx is stimulated, child should gag *VAGUS (X) *Uvula should be midline *ACCESSARY (XI) *Able to shrug shoulders symmetrically against mild pressure *HYPOGLOSSAL (XII) *Tongue should not deviate when protruded from the mouth

* *The Temporary Health Assessment Worksheet (HS-232) can be used to facilitate a neurological assessment.

*Example of Physical Exam Report 213

*Example of Physical Exam in Healthmaster This area should include descriptions of abnormal findings in Areas Examined

*Example of Physical Exam Report 213

*Neurology Screening Results from Physical Exam Report

*Neurology Screening Results from Physical Exam Report

* *It is often not black and white when trying to decide to refer to neurological clinic. *Look at the number of abnormal findings. *Look at the severity of a single finding. *The soft neuro signs in your health assessment should support the referral. *When discussing this with your school team, use your significant findings to formulate your referral question. *Consult with your team. *Consult with the neuro clinic nurse. *Consider the educational impact. *Can student be referred to PHCP?

* * http://www.neuroskills.com/brain.shtml * http://dpi.wi.gov/sped/pdf/tbi-phys-cklst.pdf * http://www.brainline.org/multimedia/interactive_brain/the_human_brain. html * http://library.med.utah.edu/neurologicexam/html/home_exam.html * http://www.pediatricneurology.com/neuro.htm * http://www.pediatricneurology.com/newpage2.htm * http://www.pediatricnews.com/index.php?id=7989&type=98&tx_ttnews[tt_ news]=75756&chash=ka03e20e36 * http://apt.rcpsych.org/content/9/2/125#bibl * http://www.ninds.nih.gov/

*Thanks and Have a Great Remainder of the School Year!