School Nursing

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School Nursing:
Technical Assistance
Manual
State of Delaware
Delaware School Nurses Association
Department of Education
Dover, Delaware
Revised:

September, 2008
-2-

Delaware State Board of Education
Jean W. Allen, President
Richard M. Farmer, Jr., Vice President
Mary B. Graham, Esquire
Jorge Melendez
Barbara B. Rutt
Dennis J. Savage
Terry Whittaker

Department of Education
John G. Townsend Building
401 Federal Street, Suite 2
Dover, Delaware 19901
Valerie A. Woodruff
Secretary of Education
Linda C. Wolfe, R.N.
Health Services
THIS PUBLICATION IS AVAILABLE IN MICROFICHE FROM THE DELAWARE PUBLIC ARCHIVES, P. O. BOX 1401, DOVER, DELAWARE
19903, AND PRINTED IN THE U.S.A.
THE DELAWARE DEPARTMENT OF EDUCATION DOES NOT DISCRIMINATE IN EMPLOYMENT OR EDUCATIONAL PROGRAMS,
SERVICES OR ACTIVITIES, BASED ON RACE, COLOR, ANTIONAL ORIGIN, SEX, AGE, OR HANDICAP IN ACCORDANCE WITH THE STATE
AND FEDERAL LAWS. INQUIRIES SHOULD BE DIRECTED TO DEPARTMENT OF EDUCATION, HUMAN RESOURCES, P.O. BOX 1402,
DOVER, DELAWARE 19903, AREA CODE (302) 739-4604.
DOCUMENT # 95-01/01/03/14

Section A - 1 - 4-2008

Section A.
1

Statutes, Regulations and
Standards
Affecting School Nurses and School
Health
Issues
I. Delaware Department of Education Regulations
II. Laws/Legal Opinions
_ Delaware Code
_ Legal Opinions
III. Standards
IV. Department of Education Licensure

The information in Section A is intended to provide current laws and regulations
related to the specialty
practice of school nursing. Although many of these documents have remained
unaltered for a number of
years, it should be noted that the content could be changed through statutory or
regulatory change at any
time. Additionally, due to the considerable length of each, in some cases only
relevant portions of the
original document have been included. It is highly recommended that Section A be
used for guiding
principles of practice. Further, updated versions and complete texts should be
consulted. Current and
complete documents can be found at:
Department of Education Regulations: www.state.de.us/research/AdminCode/title14
Delaware Laws: http://delcode.delaware.gov/index.shtml
National School Nursing Standards: www.nasn.org

Section A - 2 - 4-2008

DELAWARE DEPARTMENT OF
EDUCATION REGULATIONS
A complete set of Department of Education regulations is available at
www.state.de.us/research/AdminCode/title14
Education Regulations links:
Title 14 Education
100 Accountability
200 Administration and Operations
300 Certification
400 Construction
500 Curriculum and Instruction
600 School Climate and Discipline

2

700 Finance and Personnel
800 Health and Safety
900 Special Populations
1000 Student Activities
1100 Transportation
1500 Professional Standards Board

Section A - 3 - 4-2008
DELAWARE DEPARTMENT OF EDUCATION REGULATIONS
SECTION 800. HEALTH AND SAFETY
804 Immunizations
1.0 Definition
"School Enterer" means any child between birth and twenty (20) years inclusive entering or
being admitted to
a Delaware school district for the first time, including but not limited to, foreign exchange
students, immigrants,
students from other states and territories and children entering from nonpublic schools.
2.0 Minimum Immunizations Required for All School Enterers
2.1 All School Enterers shall have immunizations given up to four days prior to the minimum
interval or
age and shall include:
2.1.1 Four or more doses of diphtheria, tetanus, pertussis (DTaP, DTP, or other approved
vaccine)
or a combination of these vaccines. A booster dose of Td or Tdap (adult) is recommended by
the Division of Public Health for all students at age 11 or five years after the last DTaP, DTP
or DT dose was administered whichever is later. Notwithstanding this requirement:
2.1.1.1 A child who received a fourth dose prior to his or her fourth birthday shall have a
fifth dose;
2.1.1.2 A child who received the first dose of Td (adult) at or after age seven may meet this
requirement with only three doses of Td or Tdap (adult).
2.1.2 Three or more doses of inactivated polio virus (IPV), oral polio vaccine (OPV), or a
combination of these vaccines with the following exception: a child who received a third
dose
prior to the fourth birthday shall have a fourth dose.
2.1.3 Two doses of measles, mumps and rubella (MMR) vaccine. The first dose should be
administered on or after the age of 12 months. The second dose should be administered
after
the fourth birthday. Individual combination vaccines of measles, mumps, rubella (MMR) may
be used to meet this requirement.
2.1.3.1 Disease histories for measles, rubella and mumps shall not be accepted unless
serologically confirmed.
2.1.4 Three doses of Hepatitis B vaccine.
2.1.4.1 For children 11 to 15 years old age, two doses of a vaccine approved by the Center
for Disease Control (CDC) may be used.
2.1.4.2 Titers are not acceptable in lieu of completing the vaccine series and a disease
history for Hepatitis B shall not be accepted unless serologically confirmed.
2.1.5 Varicella vaccine is required beginning in the 2003-2004 school year with kindergarten.
One
grade shall be added each year thereafter so that by the 2015-2016 school year all children
in
grades kindergarten through 12 shall have received the vaccination. Beginning in the 20082009 school year new enterers into the affected grades shall be required to have two doses
of
the Varicella vaccine. The first dose shall be administered on or after the age of twelve (12)

3

months and the second at Kindergarten entry into a Delaware public school. A written
disease
history, provided by the health care provider, parent, legal guardian, Relative Caregiver or
School Enterer who has reached the statutory age of majority (18), 14 Del.C. §131(a)(9), will
be accepted in lieu of the Varicella vaccination. Beginning in the 2008-2009 school year, a
disease history for the Varicella vaccination must be verified by a health care provider to be
exempted from the vaccination.
2.2 Children who enter school prior to age four (4) shall follow current Delaware Division of
Public
Health recommendations.
3.0 Certification of Immunization
3.1 The parent, legal guardian, Relative Caregiver or a School Enterer who has reached the
statutory age of
majority (18), 14 Del.C. §131(a)(9), shall present a certificate specifying the month, day, and
year that
the immunizations were administered by a licensed health care practitioner.
3.2 According to 14 Del.C. §131, a principal or person in charge of a school shall not permit a
child to
enter into school without acceptable evidence of immunization. The parent, legal guardian,
Relative

Section A - 4 - 7-2007
Caregiver or a School Enterer who has reached the statutory age of majority (18), 14 Del.C.
§131(a)(9), shall be notified of this requirement in writing. Within 14 calendar days after
notification,
evidence must be presented to the school that the basic series of immunizations has been
initiated or
has been completed.
3.3 A school enterer may be conditionally admitted to a Delaware school district by
presenting a statement
from a licensed health care practitioner who specifies that the School Enterer has received
at least:
3.3.1 One dose of DTaP, or DTP, or DT; and
3.3.2 One dose of IPV or OPV; and
3.3.3 One dose of measles, mumps and rubella (MMR) vaccine; and
3.3.4 The first dose of the Hepatitis B series; and
3.3.5 One dose of Varicella vaccine as per 2.5.
3.4 14 DE Admin. Code 901 Education of Homeless Children and Youth 6.0 states that
"School districts
shall ensure that policies concerning immunization, guardianship and birth certificates do
not create
barriers of the school enrollment of homeless children and youth". To that end, school
districts shall as
stated in 14 DE Admin. Code "assist homeless children and youth in meeting the
immunization
requirements".
3.5 If the school enterer fails to complete the series of required immunizations the parent,
legal guardian,
Relative Caregiver or a school enterer who has reached the statutory age of majority (18),
14 Del.C.
§131(a)(9), shall be notified that the School Enterer will be excluded according to 14 Del.C.
§131.
4.0 Lost or Destroyed Immunization Record
When a student’s immunization record has been lost or destroyed by the medical provider
who administered

4

the vaccine, the parent, legal guardian, Relative Caregiver or a school enterer who has
reached the statutory
age of majority (18), 14 Del.C. §131(a)(9),shall sign a written statement to this effect and
must obtain at
least one dose of each of the immunizations as identified in 3.3. Evidence that the vaccines
were
administered shall be presented to the superintendent or his or her designee.
5.0 Exemption from Immunization
5.1 Exemption from this requirement may be granted in accordance with 14 Del.C. §131
which permits
approved medical and notarized religious exemptions.
5.2 Alternative dosages or immunization schedules may be accepted with the written
approval of the
Delaware Division of Public Health.
6.0 Verification of School Records
The Delaware Division of Public Health shall have the right to audit and verify school
immunization records to
determine compliance with the law.
7.0 Documentation
7.1 School nurses shall record and maintain documentation of each student's immunization
status.
7.2 Each student's immunization record shall be included in the Delaware Immunization
Registry.

805 The School Health Tuberculosis (TB) Control Program
1.0 Definitions
“New School Enterer” means any child between the ages of one year and twenty one (21)
years entering
or being admitted to a Delaware public school for the first time, including but not limited to,
foreign exchange
students, immigrants, students from other states and territories, and children entering from
nonpublic schools.
For purposes of this regulation, “new school enterer” shall also include any child who is re
enrolled in a
Delaware public school following travel or residency of one month in a location or facility
identified by the
Delaware Division of Public Health as an area at risk for TB exposure.
“School Staff and Extended Services Personnel” means all persons hired as full or part time
employees in a
public school who are receiving compensation to work directly with students and staff. This
includes, but is not
limited to teachers, administrators, substitutes, contract employees, bus drivers and student
teachers whether
compensated or not.
“Tuberculosis Risk Assessment” means a formal assessment by a healthcare professional to
determine
possible tuberculosis exposure through the use of a health history or questionnaire.
“Verification” means a documented evaluation of the individual’s disease status.
“Volunteers” mean those persons who give their time to help others for no monetary reward
and who share the
same air space with public school students and staff on a regularly scheduled basis.
2.0 School Staff and Extended Services Personnel

Section A - 5 - 7-2007

2.1 School staff and extended services personnel shall provide the Mantoux tuberculin skin
test results

5

from test administered within the past 12 months during the first 15 working days of
employment.
2.1.1 Tuberculin skin test requirements may be waived for public school staff and extended
services
personnel who present a notarized statement that tuberculin skin testing is against their
religious
beliefs. In such cases, the individual shall complete the Delaware Department of Education
TB
Health Questionnaire for School Employees or provide, within two (2) weeks, verification
from
a licensed health care provider or the Division of Public Health that the individual does not
pose
a threat of transmitting tuberculosis to students or other staff.
2.1.1.1 If a school staff member or extended services person, who has received a waiver
because of religious beliefs, answers affirmatively to any of the questions in the
Delaware Department of Education TB Health Questionnaire for School Employees
he/she shall provide, within two (2) weeks, verification from a licensed health care
provider or the Division of Public Health that the individual does not pose a threat of
transmitting tuberculosis to students or other staff.
2.1.2 Student teachers need not be retested if they move from district to district as part of
their student
teaching assignments.
2.2 Every fifth year, by October 15th, all public school staff and extended services personnel
shall complete
the Delaware Department of Education TB Health Questionnaire for School Employees or,
within two
(2) weeks, provide Mantoux tuberculin skin test results administered within the last twelve
(12) months.
2.2.1 If a school staff member or extended services staff member answers affirmatively to
any of the
questions in the Delaware Department of Education TB Health Questionnaire for School
Employees he/she shall provide, within two (2) weeks, verification from a licensed health
care
provider or the Division of Public Health that the individual does not pose a threat of
transmitting tuberculosis to students or other staff.
2.3 All documentation related to the School Health Tuberculosis (TB) Control Program shall
be retained in
the same manner as other confidential personnel medical information.
3.0 Volunteers
3.1 Volunteers shall complete the Delaware Department of Education’s TB Health
Questionnaire for
Volunteers in Public Schools prior to their assignment and every fifth year thereafter.
3.1.1 If the volunteer answers affirmatively to any of the questions, he/ she shall provide,
within two
(2) weeks, verification from a licensed health care provider or the Division of Public Health
that
the individual does not pose a threat of transmitting tuberculosis to the students or staff.
3.2 Each public school nurse shall collect and monitor all documentation related to the
School Health
Tuberculosis (TB) Control Program and store them in the school nurse’s office in a
confidential
manner.
4.0 New School Enterers
4.1 New school enterers shall show proof of tuberculin screening results as described in
4.1.1 and 4.1.2

6

including either results from the Mantoux Tuberculin test or the results of a tuberculosis risk
assessment. Multipuncture skin tests will not be accepted.
4.1.1 If the new school enterer is in compliance with the other school entry health
requirements, a
school nurse who is trained in the use of the Delaware Department of Education TB Risk
Assessment Questionnaire for Students may administer the questionnaire to the student’s
parent(s), guardian(s) or Relative Caregiver or to a new school enterer who has reached the
statutory age of majority (18).
4.1.1.1 If a student’s parent(s), guardian(s) or Relative Caregiver or a student 18 years or
older answers affirmatively to any of the questions, he/she shall, within two (2)
weeks, provide proof of Mantoux tuberculin skin test results or provide verification
from a licensed health care provider or the Division of Public Health that the student
does not pose a threat of transmitting tuberculosis to staff or other students.
4.2 School nurses shall record and maintain documentation relative to the School Health
Tuberculosis
(TB) Control Program.
5.0 Tuberculosis Status Verification and Follow up
5.1 Tuberculosis Status shall be determined through the use of a tuberculosis risk
assessment, tuberculin
skin test and other testing, which may include xray or sputum culture. Individuals who either
refuse
the tuberculin skin test or have positive reactions to the same, or give positive responses to
a
tuberculosis risk assessment shall provide verification from a licensed health care provider
or the

Section A - 6 - 7-2007
Division of Public Health that the individual does not pose a threat of transmitting
tuberculosis to staff
or other students.
5.1.1 Verification shall include Mantoux results recorded in millimeters (if test were
administered),
current disease status (i.e. contagious or noncontagious), current treatment (or completion
of
preventative treatment for TB) and date when the individual may return to his/her school
assignment without posing a risk to the school setting.
5.1.2 Verification from a health care provider or Division of Public Health shall be required
only once
if treatment was completed successfully.
5.1.3 Updated information regarding disease status and treatment shall be provided to the
public
school by October 15 every fifth year if treatment was previously contraindicated,
incomplete or
unknown.
5.2 In the event an individual shows any signs or symptoms of active TB infection, he/she
must be
excluded from school until all required medical verification is received by the school.
NON REGULATORY NOTE: See 14 DE Admin. Code 930 Supportive Instruction (Homebound)

811 School Health Record Keeping Requirements
1.0 Definitions
“Delaware School Health Record Form” means a form containing documentation of an
student’s health
information, which includes but is not limited to identifying information, health history,
immunizations, results
of mandated testing and screenings, medical diagnoses, long term medications and
referrals.

7

“Emergency Treatment Card” means a card containing general school emergency
procedures for the care of a
student who becomes sick or injured at school. The card contains the following information:
the student's name,
birth date, school district, school, grade, home room or teacher, home address, home
telephone, the name, place
of employment and work telephone of the parent, guardian or Relative Caregiver; two other
names, addresses
and phone numbers of individuals who can be contacted at times when the parent, guardian
or Relative
caregiver can not be reached; the name and telephone number of the family physician and
family dentist; any
medical conditions or allergies the student has; and the student's medical insurance.
2.0 Emergency Treatment Card
2.1 An Emergency Treatment Card for each public school student shall be on file in the office
of the
school nurse.
2.1.1 The information on the Emergency Treatment Card shall be shared only on a need to
know
basis as related to the education and health needs of the student and consistent with state
and
federal laws.
2.1.2 The parent, guardian or Relative Caregiver or the student if 18 years or older, or an
unaccompanied homeless youth (as defined by 42 USC 11434a) shall sign the Emergency
Treatment Card to assure they understand the purpose of the form and acknowledge the
accuracy of the information.
3.0 Delaware School Health Record Form
3.1 The Delaware School Health Record Form shall be current and shall be part of the
student’s health
record within the Cumulative Record File (14 DE Admin. Code 252) which accompanies the
student
when he or she moves to another school.
3.2. The Delaware School Health Record Form shall be maintained for the duration of the
student's
schooling and the school nurse shall use the Student Health History Update Form to keep
health
records current.
The Delaware School Health Record Form shall remain in the nurse's file during the student's
attendance in school.
3.2.1 The Delaware School Health Record Form may be maintained in hard copy or within an
electronic documentation program and transferred electronically. Beginning with the 20082009 school year, all Delaware School Health Records Forms shall be in an electronic format.
NON REGULATORY NOTE: also see 14 DE Admin. Code 251 and 252 and the Delaware Public
Archives
Document Delaware School Districts General Records Retention Schedule.
4.0 Other Required Documentation
4.1 The school nurse shall document any nursing care provided including the school name, a
three point
date, the person's (student, staff or visitor) first and last name, the time of arrival and
departure, the

Section A - 7 - 7-2007

presenting complaint, the nurse's assessment intervention and the outcome, the disposition
of the
situation, the parent or other contact, if appropriate, and the nurse's complete signature or
initials.

8

4.1.1 The school nurse shall document the care given at the time of a school based accident
by
completing the Student Accident Report Form if the student missed more than one half day
because of the accident or if the school nurse has referred the student for a medical
evaluation
regardless of whether the parent, guardian or Relative Caregiver or student if 18 years or
older, or an unaccompanied homeless youth (as defined by 42 USC 11434a) followed
through
on that request.
5.0 Submission of Records
5.1 All local school districts and charter schools shall submit the Summary of School Health
Services
Form, to the Delaware Department of Education by August 31st of each year. The form shall
include
all of the school health services provided in all schools during the fiscal year including
summer
programs.

815 Physical Examinations and Screening
1.0 Physical Examinations
1.1 All public school students shall have a physical examination that has been administered
by a licensed
medical physician, nurse practitioner or physician's assistant. The physical examination shall
have been
done within the two years prior to entry into school. Within fourteen calendar days after
notification of
the requirement for a physical examination, new enterers shall have received a physical
examination or
shall have a documented appointment with a licensed health care provider for a physical
examination.
1.1.1 The requirement for the physical examination may be waived for students whose
parent,
guardian or Relative Caregiver, or the student if 18 years or older, or an unaccompanied
homeless youth (as defined by 42 USC 11434a) presents a written declaration acknowledged
before a notary public, that because of individual religious beliefs, they reject the concept of
physical examinations.
1.1.2 The school nurse shall record all findings on the Delaware School Health Record Form
(see
14 DE Admin. Code 811) and maintain the original copy in the child’s medical file.
NON REGULATORY NOTE: See 14 DE Admin. Code 1008.3 and 14 DE Admin. Code 1009.3 for
physical examination requirements associated with participation in sports.
2.0 Screening
2.1 Vision and Hearing Screening
2.1.1 Each public school student in kindergarten and in grades 2, 4, 7 and grades 9 or 10
shall
receive a vision and a hearing screening by January 15th of each school year.
2.1.1.1 In addition to the screening requirements in 2.1.1, screening shall also be provided
to new enterers, students referred by a teacher or an administrator, and students
considered for special education.
2.1.1.1.1 Driver education students shall have a vision screening within a year prior
to their in car driving hours.
2.1.2 The school nurse shall record the results on the Delaware School Health Record Form
and
shall notify the parent, guardian or Relative Caregiver or the student if 18 years or older, or
an

9

unaccompanied homeless youth (as defined by 42 USC 11434a) if the student has a
suspected
problem.
2.2 Postural and Gait Screening
2.2.1 Each public school student in grades 5 through 9 shall receive a postural and gait
screening
by December 15th.
2.2.2 The school nurse shall record the findings on the Delaware School Health Record Form
(see
14 DE Admin. Code 811) and shall notify the parents, guardian or Relative Caregiver, or the
student if 18 years or older, or an unaccompanied homeless youth (as defined by 42 USC
11434a) if a suspected deviation has been detected.
2.2.2.1 If a suspected deviation is detected, the school nurse shall refer the student for
further evaluation through an on site follow up evaluation or a referral to the
student’s health care provider.
2.3 Lead Screening

Section A - 8 - 7-2007

2.3.1 Children who enter school at kindergarten or at age 5 or prior, shall be required to
provide
documentation of lead screening as per 16 Del.C. Ch. 26.
2.3.1.1 For children enrolling in kindergarten, documentation of lead screening shall be
provided within sixty (60) calendar days of the date of enrollment. Failure to provide
the required documentation shall result in the child's exclusion from school until the
documentation is provided.
2.3.1.2 Exemption from this requirement may be granted for religious exemptions, per 16
Del.C. §2603.
2.3.1.3 The Childhood Lead Poisoning Prevention Act, 16 Del.C., Ch. 26, requires all health
care providers to order lead screening for children at or around the age of 12 months
of age.
2.3.2 The school nurse shall document the lead screening on the Delaware School Health
Record
form. See 14 DE Admin. Code 811.

817 Administration of Medications and Treatments
1.0 Administration of Medications and Treatment
1.1 Medications, in their original container, and treatments may be administered to a public
school student
by the school nurse when a written request to administer the medication or treatment is on
file from the
parent, guardian or Relative Caregiver or the student if 18 years or older, or an
unaccompanied
homeless youth (as defined by 42 USC 11434a). The school nurse shall check the student
health
records and history for contra indications and all allergies, especially to the medications, and
shall
provide immediate medical attention if an allergic reaction is observed or make a referral if
symptoms
or conditions persist. The school nurse shall also document the student's name, the name of
medication
and treatment administered, the date and time it was administered and the dosage if
medication was
administered.
2.0 Licensed Health Care Provider
2.1 Any prescribed medication administered to a student, in addition to the requirements in
1.0, shall be

10

prescribed by a licensed health care provider. Treatment, including specialized health
procedures, shall
be signed by a licensed health care provider with directions relative to administration or
supervision.
3.0 Prescription Medications
3.1 Prescription medication shall be properly labeled with the student's name; the licensed
health care
provider's name; the name of the medication; the dosage; how and when it is to be
administered; the
name and phone number of the pharmacy and the current date of the prescription. The
medication shall
be in a container which meets United States Pharmacopoeia National Formulary standards.
3.2 Medications and dosages administered by the school nurse shall be limited to those
recommended by
the Federal Drug Administration (FDA), peer review journal that indicates doses or guidelines
that are
both safe and effective or guidelines that are specified in regional or national guidelines.
3.2.1 The prescription and the medication shall be current and long term prescriptions shall
be re
authorized at least once a year.
3.2.2 All medications classified as controlled substances shall be counted and reconciled
each
month by the school nurse and kept under double lock. Such medications should be
transported to and from school by an adult.
4.0 Non Prescription Medications
4.1 Non prescription medications may be given by the school nurse after the nurse assesses
the complaint
and the symptoms to determine if other interventions can be used before medication is
administered
and if all requirements in 1.0 have been met.
5.0 IEP Team
5.1 For a student who requires significant medical or nursing interventions, the Individual
Education
Program (IEP) team shall include the school nurse.
6.0 Assistance With Medications on Field Trips
6.1 Definitions
"Assist a Student with Medication" means assisting a student in the self administration of a
medication, provided that the medication is in a properly labeled container as hereinafter
provided.
Assistance may include holding the medication container for the student, assisting with the
opening of

Section A - 9 - 7-2007
the container, and assisting the student in self administering the medication. Lay assistants
shall not
assist with injections. The one exception is with emergency medications where standard
emergency
procedures prevail in lifesaving circumstances.
"Field Trip" means any off campus, school sponsored activity.
"Medication" means a drug taken orally, by inhalation, or applied topically, and which is
either
prescribed for a student by a physician or is an over the counter drug which a parent,
guardian or
Relative Caregiver has authorized a student to use.
"Paraeducator" mean teaching assistants or aides.

11

6.2 Teachers, administrators and paraeducator employed by a student's local school district
are authorized
to assist a student with medication on a field trip subject to the following provisions:
6.2.1 Assistance with medication shall not be provided without the prior written request or
consent
of a parent, guardian or Relative Caregiver (or the student if 18 years or older, or an
unaccompanied homeless youth (as defined by 42 USC 11434a). Said written request or
consent shall contain clear instructions including: the student's name; the name of the
medication; the dose; the time of administration; and the method of administration. At least
one copy of said written request or consent shall be in the possession of the person assisting
a
student with medication on a field trip.
6.2.2 The prescribed medication, in addition to the requirements in 1.0, shall be prescribed
by a
licensed health care provider. The medication shall be properly labeled with the student’s
name; the licensed health care provider's name; the name of the medication; the dosage;
how
and when it is to be administered; the name and phone number of the pharmacy and the
current date of the prescription. The medication shall be in a container which meets United
States Pharmacopoeia National Formulary standards.
6.2.3 A registered nurse employed by the school district in which the student is enrolled
shall
determine which teachers, administrators and paraeducators are qualified to safely assist a
student with medication. In order to be qualified, each such person shall complete a Board of
Nursing approved training course developed by the Delaware Department of Education,
pursuant to 24 Del.C. §1921. Said nurse shall complete instructor training as designated by
the Department of Education and shall submit a list of successful staff participants to the
Department of Education. No person shall assist a student with medication without written
acknowledgment that he/she has completed the course and that he/she understands the
same,
and will abide by the safe practices and procedures set forth therein.
6.2.4 Each school district shall maintain a record of all students receiving assistance with
medication pursuant to this regulation. Said record shall contain the student's name, the
name
of the medication, the dose, the time of administration, the method of administration, and
the
name of the person assisting.
6.2.5 Except for a school nurse, no employee of a school district shall be compelled to assist
a
student with medication. Nothing contained herein shall be interpreted to otherwise relieve a
school district of its obligation to staff schools with certified school nurses.
NON REGULATORY NOTE: 14 DE Admin. Code 612, Possession, Use and Distribution of Drugs
and
Alcohol addresses student self administration of a prescribed asthmatic quick relief inhaler
and student self
administration of prescribed autoinjectable epinephrine.

851 K to 12 Comprehensive Health Education Program
1.0 Program Requirements
Each school district shall have a sequential, skill based K to 12 Comprehensive Health
Education Program that
establishes a foundation of understanding the relationship between personal behavior and
health and shall
include at a minimum the following:
1.1 Identification of a district level person to coordinate the district program and a
coordinator in each

12

building to assure compliance at the building level.
1.2 Appointment of persons such as teachers, parents, school nurses, community leaders,
guidance
counselors, law enforcement officers and others with expertise in the areas of health, family
life and
safe and drug free schools and communities to serve as members of the District
Consolidated
Application Planning Committee.

Section A - 10 - 7-2007
1.3 The use of the state content standards for health education for grades K to 12 inclusive
of the core
concepts: alcohol and other drugs, injury prevention, nutrition, physical activity, family life
and
sexuality, tobacco, emotional health, personal and consumer health and community and
environmental
health with minimum hours of instruction as follows:
1.3.1 In grades K to 4, a minimum of thirty (30) hours in each grade of comprehensive
health
education and family life education of which ten (10) hours, in each grade, must address
drug
and alcohol education.
1.3.2 In grades 5 and 6, a minimum of thirty five (35) hours in each grade of comprehensive
health
education and family life education of which fifteen (15) hours, in each grade, must address
drug and alcohol education.
1.3.3 In grades 7 and 8, separate from other subject areas, a minimum of sixty (60) hours of
comprehensive health education of which fifteen (15) hours, in each grade, must address
drug
and alcohol education. If all of the 60 hours are provided in one year at grade 7 or 8, an
additional fifteen hours of drug and alcohol education must be provided in the other grade.
1.3.4 In grades 9 to 12, one half (1/2) credit of comprehensive health education is required
for
graduation of which fifteen (15) hours of this 1/2 credit course must address drug and
alcohol
education. This 1/2 credit course may be provided in the 9 th, 10th, 11th or 12th grade. In each
of the remaining three grades, fifteen (15) hours of drug and alcohol education must be
provided for all students.
1.4 Inclusion of a comprehensive sexuality education and an HIV prevention program that
stresses the
benefits of abstinence from high risk behaviors.
1.5 Inclusion of the core concepts of nutrition and family life and sexuality implemented
through Family
and Consumer Science courses.
1.6 An annual staff development plan that describes the use of effective instructional
methods as
demonstrated in sound research in the core concepts and skills inclusive of accessing
information, self
management, analyzing internal and external influences, interpersonal communication,
decision
making and goal setting and advocacy.
1.7 A description of the method(s) used to implement and evaluate the effectiveness of the
program which
shall be reported every three years as part of the Quality Review for Ensuring School and
Student
Success.

13

852 Child Nutrition

1.0 Required Policy
Each school district shall have a Child Nutrition Policy which at a minimum shall provide that:
1.1 Meals served to children are nutritious and well balanced as defined by USDA 7CFR Part
210.10
Nutrition Standards for Lunches and Menu Planning Methods and USDA 7CFR Part 220.8
Nutrition
Standards for Breakfast and Menu Planning Alternatives.
1.2 The foods sold in addition to meals be selected to promote healthful eating habits and
exclude those
foods of minimal nutritional value as defined by the Food and Nutrition Service, USDA 7 CFR
Part
210, Appendix B.
1.3 Purchasing practices ensure the use of quality products.
1.4 Students have adequate time to eat breakfast and lunch.
1.5 Nutrition education be an integral part of the curriculum from preschool to twelfth grade.
1.6 Food service personnel use training and resource materials developed by the
Department of Education
and the United States Department of Agriculture to motivate children in selecting healthy
diets.

877 Tobacco Policy
1.0 Required Policy
In order to improve the health of students and school personnel, each school district and
charter school in
Delaware shall have a policy which at a minimum:
1.1 Prohibits the use of or distribution of tobacco products in school buildings, on school
grounds, in
school leased or owned vehicles, even when they are not used for student purposes, and at
all school
affiliated functions.

Section A - 11 - 7-2007
1.2 Includes procedures for communicating the policy to students, school staff, parents,
guardians or
Relative Caregivers, families, visitors and the community at large.
1.3 Makes provisions for or refers individuals to voluntary cessation education and support
programs that
address the physical and social issues associated with nicotine addiction.
2.0 The Tobacco Policy Shall Apply to
2.1 Any building, property or vehicle leased, owned or operated by a school district, charter
school or
assigned contractor.
2.1.1 School bus operators under contract shall be considered staff for the purpose of this
policy.
2.2 Any private building or other property including automobiles or other vehicles used for
school
activities when students and staff are present.
2.3 Any non educational groups utilizing school buildings or other educational assets.
2.4 Any individual or a volunteer who supervises students off school grounds.
3.0 No School or School District Property May Be Used for the Advertising of any Tobacco
Product

881 Releasing Students to Persons Other Than Their Parent, Guardians or
Relative Caregiver
1.0 Required Policy

14

Each local school district shall have a policy which outlines the procedures for releasing
students from schools
to persons other than their parent, guardian or Relative Caregiver.

885 Safe Management and Disposal of Chemicals in the Delaware Public
School System
1.0 Mercury and Mercury Compounds
1.1 Mercury and mercury compounds, both organic and inorganic, shall not be used in the
science
classrooms in the public schools in Delaware later than January 1, 2005. Instruments which
contain
mercury such as thermometers, hydrometers, barometers, etc. shall be replaced at all grade
levels in
order to guard against spillage.
2.0 Storage of Chemicals
2.1 The storage of all chemicals shall conform to the specifications stated in Safety First:
Guidelines for
Safety in the Science or Science Related Classrooms.
3.0 Inventory of Chemicals, Hazardous and Non Hazardous
3.1 All laboratories and science storage in the Delaware public schools shall be inventoried
each year
during the month of September. The list of the chemicals shall be kept by the school
principal. The
inventory of chemicals both hazardous and nonhazardous shall contain the following
information:
3.2 Who may handle the chemical and use it;
3.3 The name of the chemical;
3.4 The amount on hand;
3.5 The location where the chemical is stored;
3.6 The date purchased; and
3.7 The date discarded.
4.0 Inventory of Surplus Chemicals
4.1 For purposes of this regulation, surplus shall refer to chemicals which are no longer
usable or needed.
4.2 Each district and charter school shall prepare a list of surplus chemicals and send a copy
to the
Education Associate, Science Environmental Education by October 15 of each year. The
Department
shall duplicate and disseminate these lists to school districts and charter schools so that
they may
negotiate, trade or exchange their surplus chemicals.
5.0 Disposal of Surplus Non Hazardous Chemicals
5.1 Disposal of surplus nonhazardous chemicals shall be carried out by the school district
and charter
school in accordance with procedures outlined in the Flinn Chemical Catalog Reference
Manual, using
trained staff.
6.0 Disposal of Non Surplus Transportable Hazardous Chemicals
6.1 Surplus hazardous chemicals such as diethyl ether, picric acid, benzoyl peroxide and
other materials
that are listed in Safety First: Guidelines for Safety in the Science or Science Related
Classrooms, must
be disposed of through the use of a licensed waste hauler.

Section A - 12 - 7-2007

6.1.1 Each district and charter school shall prepare a list of surplus hazardous chemicals and
submit

15

it to the Education Associate for Science and Environmental Education by November 15 of
each year. The Department shall arrange for a licensed waste hauler to take the chemicals
to a
proper waste facility for disposal. The cost of disposal shall be prorated among the districts
and charter schools based upon the weight of the hazardous materials.

DELAWARE DEPARTMENT OF EDUCATION REGULATIONS
SECTION 200. ADMINISTRATION AND OPERATIONS
251 Family Educational Rights and Privacy Act (FERPA)
1.0 Authority and Incorporation of Federal Regulations
1.1 The Department of Education is authorized by 14 Del. C. §4111, to adopt rules and
regulations
regarding the educational records of students in public and private schools in Delaware. This
regulation is intended to govern access to, confidentiality of, and the amendment of
educational
records in a manner consistent with the Family Educational Rights and Privacy Act (“FERPA”),
20
U.S.C. 1232g, and its implementing regulations at 34 CFR part 99, and the Individuals with
Disabilities Education Act, 20 U.S.C. 1400 et seq. and its implementing regulations.
2.0 Use and Adoption of FERPA by School Districts, Charter Schools, and Private Schools
2.1 Each school district, charter school and private school shall develop, adopt, and maintain
a written
policy regarding the educational records of its students. This policy shall address access to
such
records, the confidentiality of such records, and the method by which the records may be
amended.
The policy shall comply with FERPA and its implementing regulations.
2.2 Each school district, charter school and private school shall periodically review and
revise its policy on
educational records to ensure continued compliance with FERPA.
2.3 Nothing is this regulation shall preclude a school district, charter school, or private
school from
adopting additional policies regarding educational records so long as those regulations are
consistent
with FERPA. Nothing in this regulation shall alter a school district or a charter school’s duties
regarding educational records of children with disabilities pursuant to the Individuals with
Disabilities
Education Act.
3.0 State Adoption of FERPA
3.1 Except as otherwise provided, the Department of Education adopts the federal
regulation implementing
FERPA (34 CFR part 99), including any subsequent amendment or revision to that regulation,
to the
extent the Department maintains educational records on students in attendance in Delaware
schools.
3.2 Notwithstanding section 3.1, the Department shall not be required to annually notify
parents or eligible
students of their rights under FERPA or this regulation. School districts, charter schools, and
private
schools shall continue to be responsible for such notification. The Department may also
disclose
directory information from the educational records it maintains without prior public
notification.
3.3. Notwithstanding section 3.1, the Department shall not be required to provide a hearing
to a parent or

16

eligible student seeking to amend their educational records as provided in Subpart C of the
FERPA
regulation.
4.0 Federal Complaints and Investigations
4.1 The Family Policy Compliance Office (“FPCO”) of the U.S. Department of Education is
responsible
for monitoring compliance with FERPA by agencies to which federal education funds have
been made
available. That office will investigate, process and review violations and complaints that may
be filed
with it concerning the privacy rights of parents and students of covered agencies. The
following is the
address of the office: The Family Policy Compliance Office, U.S. Department of Education,
400
Maryland Avenue, S.W., Washington, D.C. 20202-4605. Families of students attending
schools to
which federal education funding has not been made available may also find FPCO’s
interpretations and
policy letters useful in understanding their rights under the policies required by this
regulation.

Section A - 13 - 7-2007
252 Required Educational Records and Transfer and Maintenance of
Educational Records
1.0 Definitions
The following words and terms, when used in this regulation, shall have the following
meaning unless the
context clearly states otherwise:
“Court Orders” shall mean any written direction from a court of competent jurisdiction
directed to the student
or affecting the student’s care or custody.
“Discipline Record” shall mean information about any and all periods of out of school
suspension or of
expulsion from the regular school setting imposed on a student as a result of an infraction of
the school or
district’s code of conduct or other rules.
“Emergency Treatment Card” shall mean the card containing the general emergency
information and
procedures for the care of a student when the student becomes sick or injured in school as
required in 14 DE
Admin Code 811.1.1.
“Identifying Data” shall mean the name of the student, date of birth, sex, race and ethnicity,
address, telephone
number, Delaware student identification number and the name of the parent(s), guardian(s)
or Relative
Caregiver.
“Progress Report” shall mean a single record maintained for each student in kindergarten
through grade 8 that
contains end of year and up to date grades; standardized test(s) scores such as the DSTP
and attendance data for
each year of the student’s attendance.
“School Health Record” shall mean the form required by 14 DE Admin Code 811.2.0 for
Delaware public
school students.
“Student Transcript” shall mean a single record maintained for each student in grades 9 and
above that

17

contains the following: end of year and up to date grades; credits earned; class rank; Grade
Point Average
(GPA); withdrawal or graduation date; standardized test(s) scores such as the DSTP, SAT,
PSAT, ACT;
attendance data and school activities. If applicable, a list of the career technical
competencies achieved by a
student enrolled in a specific career technical program shall also be included.
2.0 Education Records Required by Schools in Delaware
2.1 Each Delaware school shall maintain a Cumulative Record File either as an electronic or
paper file for
each student enrolled.
2.1.1 The student Cumulative Record File shall contain the Emergency Treatment Card,
Identifying
Data, School Health Record, Progress Report, Student Transcript (for students in grades 9
and
above) and Discipline Record.
2.1.2 The student Cumulative Record File shall also contain any Court Orders in the school or
district’s possession, to the extent the school or district maintains such documents for an
individual student.
2.1.3 In addition, the Cumulative Record File for a child with a disability as defined in 14 DE
Admin Code 925 shall contain any records related to the identification, evaluation,
placement,
and provision of a free appropriate public education. Such documents may be collected and
maintained separately.
3.0 Transfer of the Records of Public School and Private Schools Students
3.1 When a student transfers from a public school, private school or an educational program
operated by
the Department of Services for Children Youth and Their Families to any other school in
Delaware, the
receiving school shall immediately request the Cumulative Record File from the sending
school or
program.
3.2 The Cumulative Record File shall follow each student transferred from one school to
another including
files for each student with disabilities transferred from one school to another.
3.2.1 Public schools, school districts, private schools and educational programs operated by
the
Department of Services for Children Youth and Their Families shall promptly transfer a
student’s Cumulative Record File upon the request of a receiving school.
3.2.2 Unpaid student fees or fines shall not be a basis for a public school, school district or
an
educational program operated by the Department of Services for Children Youth and Their
Families to deny or to delay transfer of the Cumulative Record File.
3.2.3 Students shall not be denied enrollment into a public school on the grounds that the
student’s
Cumulative Record File has not been received.

Section A - 14 - 7-2007
3.3 Before transferring student records, a public school, school district or private school shall
specifically
confirm that the Cumulative Record File contains the student’s Discipline Record.
3.4 When students transfer to a Delaware school from any other school including a school in
a foreign
country the receiving school is responsible for having the transcripts evaluated.
4.0 Maintenance of the Education Records of Public Schools

18

4.1 The Delaware School District General Records Retention Schedule published by the
Delaware Public
Archives shall be followed as to the length of time and special considerations for the
maintenance of
education records.
4.2 Contracts for storage of student records of graduates, withdrawals and special education
students for
4.3 district storage, shall be initiated between the school district and the Delaware Public
Archives.
4.4 The Cumulative Record Files for students who have graduated from or who left school
prior to
4.5 graduation from high school shall be stored at the school or district of last attendance or
in the
4.6 Delaware Public Archives.
5.0 Destruction of Education Records of Public Schools
5.1 The Delaware School District General Records Retention Schedule published by the
Delaware Public
Archives shall be followed as to the length of time and special considerations for the
destruction of any
education records.
5.2 The destruction of educational records of children with disabilities shall also comply with
the
requirements of 14 DE Admin Code 925.

255 Definitions of Public School, Private School and Nonpublic School
1.0 Public School
A public school shall mean a school or Charter School having any or all of grades
kindergarten through twelve,
supported primarily from public funds and under the supervision of public school
administrators. It also shall
include the agencies of states and cities which administer the public funds.
2.0 Private School
A private school shall mean a school having any or all of grades kindergarten through
twelve, operating under a
board of trustees and maintaining a faculty and plant which are properly supervised and
shall be interpreted
further to include an accredited and/or approved college or university.
3.0 Nonpublic School
A nonpublic school shall mean a private school as that term is defined in paragraph 2.0 of
this regulation or any
homeschool defined in 14 Del. C. §2703A.

275 Charter Schools
1.0 Purpose and Effect
1.1 The purpose of these regulations is to provide rules to govern the implementation of 14
Del. C. Ch. 5
(hereafter, the “Charter School Law”).
1.2 These regulations establish the requirements for applying for a charter to operate a
public school, and
for opening and operating the school, when a charter is granted by the Department of
Education with
the approval of the State Board of Education.
1.3 These regulations affect students who attend Charter Schools, the parents and other
caregivers of these
students, the directors, staff and administrators of the Charter Schools, and the students,
staff,
administrators and boards of the reorganized school districts of the State.

19

1.4 These regulations shall bind all Charter Schools and are incorporated into all charters
approved by the
Department with the consent of the State Board.
2.0 Definitions
2.1 The following definitions apply for purposes of interpreting the Charter School Law and
these
regulations:
“Accountability Committee”: Any Charter School Accountability Committee established by
the
Department to review and report to the Department as provided in Sections 511 and 515 of
the Charter
School Law.

Section A - 15 - 7-2007
“Applicant”: A legal entity organized under the Delaware General Corporation Law that has
applied
to the Department for, but not yet received, a charter to operate a charter school, or the
renewal or
modification of such a charter, as the context indicates.
“Audit”: An informal financial, programmatic, or compliance audit of a charter school.
“Charter Holder”: The legal entity organized under the Delaware General Corporation Law to
which
a charter is issued by the Department with the approval of the State Board.
“Charter School”: A non home based full time public school that is operated in an approved
physical
plant under a charter granted by the Department with the approval of the State Board for
the personal
physical attendance of all students.
“DSTP”: The Delaware Student Testing Program established at 14 Del.C. §151, et.seq., and,
as the
context requires, the assessments administered pursuant to the program.
“Department”: The Delaware Department of Education
“First Instructional Day”: The first day a Charter School is open with students in attendance.
“Formal Review”: The lawful investigation of a Charter School to determine whether the
school is
violating the terms of its charter. Formal reviews may include, but are not limited to, on site
visits,
inspection of educational records and other documents, and interviews of parents, Charter
School
employees and others with knowledge of the school’s operations and educational programs.
“Founding Board of Directors”: The duly elected Board of Directors of an Applicant at the
time the
original application for a charter is filed with the Department.
“Parent”: The natural or adoptive parent, or the legal guardian, of a student enrolled in the
charter
school. “Parent” also includes individuals authorized to act as Relative Caregivers under the
provisions
of 14 Del. C. §202(e)(2).
“Performance Review”: Reserved
“Renewal”: The approval of an application to continue operating an existing Charter School
for an
additional five year period, available after the school has been in operation for three years.
“Secretary”: The Secretary of the Delaware Department of Education.
“State Board”: The Delaware State Board of Education.
3.0 Application Process

20

3.1 Application Deadlines: Applications to establish new Charter Schools must be submitted
to the
Department between November 1st and December 31st for schools preparing to admit
students the
second September 1st thereafter.
3.2 All applications, whether for an original charter, a modification of a charter or the
Renewal of a
charter, shall be made on forms approved by the Department.
3.3 The Department may require a criminal background check on any person involved in the
preparation
of an application, whether for an original charter, a major modification or a charter Renewal,
and on
any person involved in the development of the proposed Charter School.
3.4 An original and ten (10) copies of a completed application must be received by the
Department by the
application deadline in order for the application to be considered. Incomplete applications, or
applications received after the deadline, will not be considered.
3.5 All written communications from the Department or the Accountability Committee to an
Applicant
shall be sent to the contact person identified in the application, at the address provided in
the
application. An Applicant is responsible for notifying the Department in writing of any
change in the
contact person or contact address after its application is submitted.
3.6 An application is not complete unless all of the following requirements are met:
3.6.1 All questions on the application form are answered.
3.6.2 All documentation required by the application form or subsequently requested by the
Department or the Accountability Committee is received.
3.7 No application for a new Charter School will be accepted by the Department in any year
in which the
Department with the approval of the State Board has decided not to accept applications.
3.8 Applications will not remain pending from year to year. Applications that do not result in
the issuance
of a charter must be resubmitted in full in subsequent years to be considered in subsequent
years.
3.9 The State Board of Education may designate one or more of its members to sit as
nonvoting members
of the Accountability Committee.
3.10 In deciding whether to approve or disapprove any application for an original charter, a
major
modification of a charter or the Renewal of a charter, the Secretary and State Board shall
base the
decision on the record. The record shall consist of the application and any documents filed
therewith

Section A - 16 - 7-2007
in support of the application, the preliminary and final report of the Accountability
Committee, any
response or other evidence, oral or otherwise, provided by the Applicant to the
Accountability
Committee prior to the issuance of its final report, any comments received at any public
hearing
conducted pursuant to the provisions of the Charter School Law, including comments made
at any such
hearing by the applicant in response to the Accountability Committee’s final report and any
written or

21

electronic comments received at or before any such public hearing. No other evidence shall
be
considered. Written and electronic comments must be received by the Education Associate
for Charter
Schools no later than the beginning of the public hearing to be included in the record.
4.0 Standards and Criteria for Granting Charter
4.1 Applicant Qualifications
4.1.1 The Applicant must demonstrate that its board of directors has and will maintain
collective
experience, or contractual access to such experience, in the following areas:
4.1.1.1 Research based curriculum and instructional strategies, to particularly include the
curriculum and instructional strategies of the proposed educational program.
4.1.1.2 Business management, including but not limited to accounting and finance.
4.1.1.3 Personnel management.
4.1.1.4 Diversity issues, including but not limited to outreach, student recruitment, and
instruction.
4.1.1.5 At risk populations and children with disabilities, including but not limited to
students eligible for special education and related services.
4.1.1.6 School operations, including but not limited to facilities management.
4.1.2 The application must identify the certified teachers, the parents and the community
members
who have been involved in the preparation of the application and the development of the
proposed Charter School.
4.1.3 The Applicant’s bylaws must be submitted with the application and must demonstrate
that:
4.1.3.1 The Charter Holder’s board of directors will include a certificated teacher employed
as a teacher at the Charter School and a Parent of a currently enrolled student of the
school no later than the school’s First Instructional Day;
4.1.3.2 The Applicant’s business is restricted to the opening and operation of: Charter
Schools, before school programs, after school programs and educationally related
programs offered outside the traditional school year.
4.1.3.3 The board of directors will meet regularly and comply with the Freedom of
Information Act, 29 Del.C. Ch. 100 in conducting the Charter School’s business.
4.2 Student Performance
4.2.1 Minimum Requirements
4.2.1.1 The Applicant must agree and certify that it will comply with the requirements of the
State Public Education Assessment and Accountability System pursuant to 14 Del.C.
§§151, 152, 153, 154, and 157 and Department rules and regulations implementing
Accountability, to specifically include the Delaware Student Testing Program.
4.2.1.2 The Applicant must demonstrate that it has established and will apply measurable
student performance goals on the assessments administered pursuant to the Delaware
Student Testing Program (DSTP), and a timetable for accomplishment of those
goals.
4.2.1.3 The Applicant must agree and certify that the Charter School’s average student
performance on the DSTP assessments in each content area will meet or exceed the
statewide average student performance of students in the same grades for each year
of test administration, unless the student population meets the criteria established in
Section 4.2.2.
4.2.2 Special Student Populations
4.2.2.1 An Applicant for a charter proposing enrollment preferences for students at risk of
academic failure shall comply with the minimum performance goals established in
Subsections 4.2.1.2 and 4.2.1.3. This requirement shall be waived where the
Applicant demonstrates to the satisfaction of the Department and State Board that the
Charter School will primarily serve at risk students and will apply performance goals
and timetables which are appropriate for such a student population.

22

Section A - 17 - 7-2007

4.2.2.2 An Applicant for a charter proposing an enrollment preference other than a
preference for students at risk of academic failure shall comply with the Section.
4.2.1 In addition, the Department, with the approval of the State Board, may require such an
Applicant to establish and apply additional and higher student performance goals consistent
with the needs and abilities of the student population likely to be served as a result of the
proposed enrollment preferences.
4.2.3 If the Applicant plans to adopt or use performance standards or assessments in
addition to the
standards set by the Department or the assessments administered pursuant to the DSTP,
the
application must specifically identify those additional standards or assessments and include
a
planned baseline acceptable level of performance, measurable goals for improving
performance and a timetable for accomplishing improvement goals for each additional
indicator or assessment. The use of additional performance standards or assessments shall
not
replace, diminish or otherwise supplant the Charter School’s obligation to meet the
performance standards set by the Department or to use the assessments administered
pursuant
to the DSTP.
4.3 Educational Program
4.3.1 The application must demonstrate that the school’s proposed program, curriculum and
instructional strategies are aligned to State content standards, meet all grade appropriate
State
program requirements, and in the case of any proposed Charter High School, includes driver
education. The educational program shall include the provision of extra instructional time for
at risk students, summer school and other services required to be provided by school
districts
pursuant to the provisions of 14 Del.C. §153. Nothing in this subsection shall prevent an
Applicant from proposing high school graduation requirements in addition to the state
graduation requirements.
4.3.2 The application must demonstrate that the Charter School’s educational program has
the
potential to improve student performance. The program’s potential may be evidenced by:
4.3.2.1 Academically independent, peer reviewed studies of the program conducted by
persons or entities without a financial interest in the educational program or in the
proposed Charter School;
4.3.2.2 Prior successful implementation of the program; and
4.3.2.3 The Charter School’s adherence to professionally accepted models of student
development.
4.3.3 The application must demonstrate that the Charter School’s educational program and
procedures will comply with applicable state and federal laws regarding children with
disabilities, unlawful discrimination and at risk populations, including but not limited to the
following showings.
4.3.3.1 The school’s plan for providing a free appropriate public education to students with
disabilities in accordance with the Individuals with Disabilities Education Act, with
14 Del. C. Ch. 31 and with 14 DE Admin. Code 925, specifically including a plan for
having a continuum of educational placements available for children with
disabilities.
4.3.2.2 The school’s plan for complying with Section 504 of the Rehabilitation Act of 1973
and with the Americans with Disabilities Act of 1990.
4.3.3.3 The school’s plan for complying with Titles VI and VII of the Civil Rights Act of
1964.
4.3.3.4 The school’s plan for complying with Title IX of the Education Amendments of

23

1972.
4.4 Economic Viability.
4.4.1 The application must demonstrate that the school is economically viable and shall
include
satisfactory documentation of the sources and amounts of all proposed revenues and
expenditures during the school’s first three years of school operation after opening for
instructional purposes. There must be a budgetary reserve for contingencies of not less than
2.0% of the total annual amount of proposed revenues. In addition, the application shall
document the sources and amounts of all proposed revenues and expenditures during the
start
up period prior to the opening of the school.

Section A - 18 - 7-2007
4.4.2 The Department may require that the Applicant submit data demonstrating sufficient
demand
for Charter School enrollment if another Charter School is in the same geographic area as
the
Applicant’s proposed school. Such data may include, but is not limited to, enrollment waiting
lists maintained by other Charter Schools in the same geographic area and demonstrated
parent interest in the Applicant’s proposed school.
4.4.3 The application shall identify with specificity the proposed source(s) of any loan(s) to
the
Applicant including, without limitation, loans necessary to implement the provisions of any
major contract as set forth below, and the date by which firm commitments for such loan(s)
will be obtained.
4.4.4 The application shall contain a timetable with specific dates by which the school will
have in
place the major contracts necessary for the school to open on schedule. “Major contracts”
shall include, without limitation, the school’s contracts for equipment, services (including
bus
and food services, and related services for special education), leases of real and personal
property, the purchase of real property, the construction or renovation of improvements to
real
property, and insurance. Contracts for bus and food services must be in place no later than
August 1st of the year in which the school proposes to open and August 1st of each year
thereafter. Contracts for the lease or purchase of real property, or the construction or
renovation of improvements to real property must be in place sufficiently far in advance so
that the Applicant might obtain any necessary certificate of occupancy for the school
premises
no later than June 15th of the year in which the school proposes to open.
4.4.5 Reserved
4.5 Attendance, Discipline, Student Rights and Safety
4.5.1 The application must include a draft “Student Rights and Responsibilities Manual” that
meets
applicable constitutional standards regarding student rights and conduct, including but not
limited to discipline, speech and assembly, procedural due process and applicable
Department
regulations regarding discipline.
4.5.1.1 The “Student Rights and Responsibilities Manual” must comply with the Gun Free
Schools Act of 1994 (20 U.S.C.A. §8921) and Department Regulation 878.
4.5.1.2 The application must include a plan to distribute the “Student Rights and
Responsibilities Manual” to each Charter School student at the beginning of each
school year. Students who enroll after the beginning of the school year shall be
provided with a copy of the “Student Rights and Responsibilities Manual” at the time
of enrollment.

24

4.5.2 The application must include the process and procedures the Charter School will follow
to
comply with the following laws:
4.5.2.1 14 Del.C. Ch. 27 and applicable Department regulations regarding school
attendance, including a plan to distribute attendance policies to each Charter School
student at the beginning of each school year. Students who enroll after the beginning
of the school year shall be provided with a copy of the attendance policy at the time
of enrollment.
4.5.2.2 11 Del.C. Ch. 85 and applicable Department regulations regarding criminal
background checks for public school related employment.
4.5.2.3 14 Del.C. §4112 and applicable Department regulations regarding the reporting of
school crimes.
4.5.2.4 The Family Educational Rights and Privacy Act (FERPA) and implementing federal
and Department regulations regarding disclosure of student records.
4.5.2.5 The provision of free and reduced lunch to eligible students pursuant to any
applicable state or federal statute or regulation.
4.5.3 The requirement that the Applicant provide for the health and safety of students,
employees
and guests will be judged against the needs of the student body or population served.
Except
as otherwise required in this regulation, the Applicant must either agree and certify that the
services of at least one (1) full time nurse will be provided for each facility in which students
regularly attend classes, or demonstrate that it has an adequate and comparable plan for
providing for the health and safety of its students. Any such plan must include the Charter
School’s policies and procedures for routine student health screenings, for administering
medications to students (including any proposed self administration), for monitoring chronic

Section A - 19 - 7-2007

student medical conditions and for responding to student health emergencies. Any applicant
which receives funding equivalent to the funding provided to school districts for one or more
school nurses shall provide its students the full time services of a corresponding number of
registered nurses.
5.0 Nature of Charter
5.1 When granted, a charter is an authorization for the Charter Holder to open and operate a
Charter
School in accordance with the terms of the charter, including the terms of any conditions
placed on the
charter by the Department with the approval of the State Board.
5.1.1 It is the responsibility of the Charter Holder to notify the Department in writing of its
compliance with any time frames or other terms or conditions contained in or imposed on
the
charter. The Department may require the Charter Holder to produce satisfactory evidence,
including written documentation, of compliance.
5.2 Compliance with the charter, including compliance with the terms of any conditions
placed on the
charter, is a condition precedent to the authority to open and operate the Charter School.
Failure to
comply with the terms of the charter and any conditions placed on the charter, including
deadlines,
operates as a forfeiture of the authority to open the Charter School regardless of previous
approval.
These regulations are incorporated into and made a part of each charter approved by the
Department
with the consent of the State Board. A Charter School’s failure to comply with these
regulations may
be treated as a failure on the part of the school to comply with its charter.

25

6.0 Funding
6.1 The Department may withhold State and local funding from a Charter Holder not in
compliance with
the terms of the charter being funded, including compliance with any conditions placed on
such
charter.
6.2 The Department may withhold State and local funding from a Charter Holder while one
or more of its
charters is under formal review.
6.3 State and local funding of any charter on probationary status will be released in
accordance with the
terms of the probation.
6.4 Federal funding for a Charter Holder and under the control of the Department will be
disbursed
according to the laws, regulations and policies of the federal program providing the funding
and the
terms of any applicable federal grant approval including state requirements.
7.0 Reserved
8.0 Enrollment Preferences, Solicitations and Debts
8.1 Enrollment Preferences
8.1.1 An Applicant to establish a new Charter School shall indicate in its application whether
children of the Charter School’s founders will be given an enrollment preference. If a
founders’ preference will be given, the application shall include the standard adopted by the
Founding Board of Directors to determine the founders. The standard used to determine the
founders shall be consistent with the requirements of Section 506(b)(4) of the Charter
School
Law. If the application is approved, the Charter Holder shall provide the Department with the
identity of its founders no later than March 1 immediately preceding the First Instructional
Day.
8.2 Solicitations.
8.2.1 Any person or entity soliciting contributions, gifts or other funding on behalf of or for
the
benefit of an existing or potential Charter School shall notify the person or entity solicited
that
enrollment of an individual student in the Charter School is not contingent on, or assured by,
any such contribution, gift or other funding.
8.2.2 Written notices of fund raising activities for the benefit of a Charter School must
contain the
following statement: “The [name of school] is a public school. Contributions and gifts are not
required for admission to the school and will in no way affect or improve a student’s
opportunity for admission.”
8.3 Debts
8.3.1 Any person or entity offering a loan to a Charter School must be advised by the school
that
debts of the school are not debts of the State of Delaware and that neither the State nor any
other agency or instrumentality of the State is liable for the repayment of any indebtedness.

Section A - 20 - 7-2007
9.0 Modifications of Charters
9.1 A charter holder may apply to the Department for a modification of the charter following
the granting
of the charter.
9.2 The application shall be submitted on a form approved by the Department and shall
specify the exact
modification requested and describe the need for the modification.

26

9.3 The standards for deciding a modification application shall be as provided in Section 4.0
of these
regulations for the original grant of the charter.
9.4 The following are considered applications for a new charter and shall not be processed or
considered as
a modification application:
9.4.1 An application to collectively change the mission, goals for student performance and
educational program of the charter school; or
9.4.2 An application, at any time before the First Instructional Day, to offer educational
services at
a site other than the site approved as part of the school’s charter, when the charter has
previously been amended to change the school’s site; or
9.4.3 An application to replace, remove or permit the school to operate without an
educational
management organization providing administrative, managerial or instructional staff or
services to the charter holder at any time before the First Instructional Day.
9.5 An application for a major or minor charter modification may not be filed while a school’s
charter is
on formal review, except where the Secretary determines that the requested modification is
unrelated
to the reason the school’s charter has been placed on formal review or where the
modification
addresses the reason the school was placed on formal review provided the modification is
filed before
the preliminary report is approved by the Accountability Committee.
9.6 A charter shall not be modified to permit a charter school’s first instructional day to
occur later than
the third September 15th after the date the charter is originally granted. In the event that the
first
instructional day does not occur by that date, the charter shall be deemed forfeited and the
authority to
open and operate a charter school expired. Further, no charter shall be modified to permit a
charter
school to obtain a certificate of occupancy, either temporary or final, for all or any part of
the premises
to be occupied by the school, later than June 15 immediately preceding the authorized
opening date of
the school.
9.7 An increase or decrease of up to 5% in a charter school’s current authorized enrollment
shall not be
considered a modification of the school’s charter. Any modification application to increase or
decrease a charter school’s current authorized enrollment by more than 5% must be filed
between
November 1st and December 31st and, if approved, shall be effective the following school
year.
9.8 Major modifications
9.8.1 A major modification is any proposed change to a charter, including proposed changes
to any
condition placed on the charter, which would:
9.8.1.1 Replace, remove or permit the school to operate without an educational
management
organization providing administrative, managerial or instructional staff or services to
the charter school at anytime on or after the First Instructional Day; or
9.8.1.2 After enrollment preferences; or
9.8.1.3 Result in an increase or decrease in the school’s total authorized enrollment of more

27

than 15%, provided further the major modification request must be filed between
November 1st and December 31st and, if approved, shall be effective the following
school year; or
9.8.1.4 After grade configurations; or
9.8.1.5 At any time after the First Instructional Day, offer educational services at a site other
than the site approved as part of the school’s charter, except where such change is
the unavoidable result of a loss by fire or other “casualty” as that term is defined in
Black’s Law Dictionary; or
9.8.1.6 At any time before the First Instructional Day, offer educational services at a site
other than the site approved as part of the school’s charter, provided that the charter
has not previously been amended to change the school’s site; or
9.8.1.7 Alter any two of the following: the school’s mission, goals for student performance,
or educational program; or
9.8.1.8 Alter the charter school’s performance agreement with the Department.
9.9 Minor modifications

Section A - 21 - 7-2007
9.9.1 A minor modification is any proposed change to a charter, including proposed changes
to any
condition placed on the charter, which is not a major modification. Minor modifications
include, but are not limited to:
9.9.1.1 Changes to the name of either the charter school or charter holder; or
9.9.1.2 The first extension of any deadline imposed on the charter school or charter holder
by thirty (30) working days or less (or by 15 calendar days in the case of the First
Instructional Day); or
9.9.1.3 Changes in the standards or assessments used to judge student performance (other
than the State standards or the assessments administered pursuant to the DSTP); or
9.9.1.4 In the case of a charter school which is open with students in attendance, offering
educational services at a site other than, or in addition to, the site approved as part of
the school’s charter, when use of the approved site has unavoidably been lost by
reason of fire or other casualty as that term is defined in Black’s Law Dictionary; or
9.9.1.5 Changes to alter not more than one of the following: the school’s mission, goals for
student performance, or educational program; or
9.9.1.6 An increase or decrease in the school’s total authorized enrollment of more than 5%,
but not more than 15%, provided further the minor modification request must be
filed between November 1st and December 31st and, if approved, shall be effective
the following school year; or
9.9.1.7 Alter, expand or enhance existing or planned school facilities or structures, including
any plan to use temporary or modular structures, provided that the applicant
demonstrates that the school will maintain the health and safety of the students and
staff and remain economically viable as provided in 4.4 above; or
9.9.1.8 Any change in the school’s agreement with an educational management organization
other than as set forth in 9.4.3 and 9.8.1.1 above; or
9.9.1.9 A change to the current authorized number of hours, either daily or annually,
devoted
to actual school sessions. Regardless of any proposed change, the school shall
maintain the minimum instructional hours required by 14 Delaware Code; or
9.9.1.10 A change in the terms of the current site facilities arrangements including, but not
limited to, a lease to a purchase or a purchase to a lease arrangement; or
9.9.2 The Secretary may decide the minor modification application based on the supporting
documents supplied with the application unless the Secretary finds that additional
information
is needed from the applicant.
9.9.3 The Secretary may refer a minor modification request to the Accountability Committee
for
review if the Secretary determines, in her/his sole discretion, that such review would be

28

helpful in her/his consideration of the application. If the Secretary refers a minor
modification application to the Accountability Committee, she/he may decide the application
based on any report from the Committee and the supporting documents related to the
application. The applicant for a minor modification shall be notified if the minor modification
request has been forwarded to the Accountability Committee. The applicant may be asked to
provide additional supporting documentation.
9.9.4 The Secretary may deny a minor modification request if the supporting documentation
is
incomplete or insufficient provided the applicant has been advised additional information
was
needed.
9.9.5 Upon receiving an application for a minor modification, the Secretary shall notify the
State
Board of the application and her/his decision on whether to refer the application to the
Accountability Committee.
9.9.6 The meeting and hearing process provided for in Section 511(h), (i) and (j) of the
Charter
School Law shall not apply to a minor modification application even where the Secretary
refers the application to the Accountability Committee.
9.9.7 Decisions for minor modifications to a charter shall be decided by the Secretary, with
the
concurrence of the State Board of Education, within 30 working days from the date the
application was filed, unless the timeline is waived by the Secretary and the applicant.
10.0 Renewals
10.1 Charters are granted for an initial period of 4 years of operation and are renewable
every 5 years
thereafter.

Section A - 22 - 7-2007
10.2 Renewals are only available to the current Charter Holder and may not be used to
transfer a charter to a
different legal entity.
10.3 Charters shall be renewed only if the school receives a satisfactory Performance
Review.
11.0 Public Hearings
11.1 Any public hearing conducted by the Department pursuant to the provisions of the
Charter School Law
shall be conducted as a joint public hearing with the State Board of Education.

Section A - 23 - 7-2007
DELAWARE DEPARTMENT OF EDUCATION REGULATIONS
SECTION 600. DISCIPLINE AND SCHOOL CLIMATE
603 Compliance with the Gun Free Schools Act
1.0 Written Policy Required
Each school district and charter school requesting assistance under the Elementary and
Secondary Education
Act (ESEA) shall have a written policy implementing the Gun Free Schools Act [(20 USC
§4141) (20 USC
§7151)] and 11 Del.C. §1457(j) or its successor statute. At a minimum, the policy must
contain the following
elements:
1.1 A student who is determined to have brought a firearm to school, or to have possessed a
firearm at
school, shall be expelled for not less than one year.
1.2 Modification to the expulsion requirement may be made on a case by case basis. Any
modification to

29

the expulsion requirement must be made in writing.
1.3 The definition of "firearm" shall be the same as the meaning given to the term in 18 USC
§921(a).
2.0 Submission of the Policy to the State Department of Education
Each school district and charter school requesting assistance under the ESEA shall submit
the following to the
Delaware Department of Education by June 1 each year, in such form as the Department
requires:
2.1 An assurance that its policies comply with this regulation and with 11 Del.C. §1457(j) or
its successor
statute.
2.2 Descriptions of the expulsions imposed under 11 Del.C. §1457(j) or its successor statute
and under the
policy implemented in accord with this regulation.
3.0 Individuals with Disabilities Act
Nothing in this regulation shall alter a district or charter school's duties pursuant to the
Individuals with
Disabilities Education Act.

612 Possession, Use or Distribution of Drugs and Alcohol
1.0 The Following Policy on the Possession, Use, or Distribution of Drugs and Alcohol Shall
Apply to All
Public School Districts
1.1 The possession, use and/or distribution of alcohol, a drug, a drug like substance, a look
alike substance
and drug paraphernalia are wrong and harmful to students and are prohibited within the
school
environment.
1.2 Student lockers are the property of the school and may be subjected to search at any
time with or
without reasonable suspicion.
1.3 Student motor vehicle use to and in the school environment is a privilege which may be
extended by
school districts to students in exchange for their cooperation in the maintenance of a safe
school
atmosphere. Reasonable suspicion of a student's use, possession or distribution of alcohol, a
drug, a
drug like substance, a look alike substance or drug paraphernalia in the school environment,
may result
in the student being asked to open an automobile in the school environment to permit
school
authorities to look for such items. Failure to open any part of the motor vehicle on the
request of
school authorities may result in the police being called to conduct a search, and will result in
loss of the
privilege to bring the vehicle on campus.
1.4 All alcohol, drugs, drug like substances, look alike substances and drug paraphernalia
found in a
student's possession shall be turned over to the principal or designee, and be made
available, in the
case of a medical emergency, for identification. All substances shall be sealed and
documented, and, in
the case of substances covered by 16 Del.C. Ch. 47, turned over to police as potential
evidence.
2.0 The Following Definitions Shall Apply to This Policy and Will be Used in All District Policies

30

"Alcohol" shall mean alcohol or any alcoholic liquor capable of being consumed by a human
being, as defined
in 4 Del.C. §101 including alcohol, spirits, wine and beer.
"Distribute" "Distributing" or "Distribution" shall mean the transfer or attempted transfer of
alcohol, a
drug, a look alike substance, a drug like substance, or drug paraphernalia to any other
person with or without the
exchange of money or other valuable consideration.
"Drug" shall mean any controlled substance or counterfeit substance as defined in 16 Del.C.
§4701 including,

Section A - 24 - 7-2007

for example, narcotic drugs such as heroin or cocaine, amphetamines, anabolic steroids, and
marijuana, and
shall include any prescription substance which has been given to or prescribed for a person
other than the
student in whose possession it is found.
"Drug Like Substance" shall mean any noncontrolled and nonprescription substance capable
of producing a
change in behavior or altering a state of mind or feeling, including, for example, some over
the counter cough
medicines, certain types of glue, caffeine pills and diet pills. The definition of drug like
substance does not
include tobacco or tobacco products which are governed by regulation 877 Tobacco Policy.
"Drug Paraphernalia" shall mean all equipment, products and materials as defined in 16
Del.C. §4701
including, for example, roach clips, miniature cocaine spoons and containers for packaging
drugs.
"Expulsion" shall mean exclusion from school for a period determined by the local district not
to exceed the
total number of student days. The process for readmission shall be determined by the local
district.
"Look Alike Substance" shall mean any noncontrolled substance which is packaged so as to
appear to be, or
about which a student makes an express or implied representation that the substance is, a
drug or a
noncontrolled substance capable of producing a change in behavior or altering a state of
mind or feeling. See 16
Del.C. §4752A.
"Nonprescription Medication" shall mean any over the counter medication; some of these
medications may
be a "drug like substance."
"Possess" "Possessing" or "Possession" shall mean that a student has on the student's
person, in the student's
belongings, or under the student's reasonable control by placement of and knowledge of the
whereabouts of,
alcohol, a drug, a look alike substance, a drug like substance or drug paraphernalia.
"Prescription Drugs" shall mean any substance obtained directly from or pursuant to a valid
prescription or
order of a practitioner, as defined in 16 Del.C. §4701(24), while acting in the course of his or
her professional
practice, and which is specifically intended for the student in whose possession it is found.
"School Environment" shall mean within or on school property, and at school sanctioned or
supervised
activities, including, for example, on school grounds, on school buses, at functions held on
school grounds, at

31

extra curricular activities held on and off school grounds, on field trips and at functions held
at the school in the
evening.
"Use" shall mean that a student is reasonably known to have ingested, smoked or otherwise
assimilated
alcohol, a drug or a drug like substance, or is reasonably found to be under the influence of
such a substance.
3.0 Each School District Shall Have a Policy on File and Update it Periodically. The Policy Shall
Include, as a
Minimum the Following
3.1 A system of notification of each student and of his/her parent, guardian or Relative
Caregiver at the
beginning of the school year, of the state and district policies and regulations. In addition a
system for
the notification of each student and his/her parent, guardian or Relative Caregiver whenever
a student
enrolls or re enrolls during the school year of the state and district policies and regulations.
3.2 A statement that state and district policies shall apply to all students, except that with
respect to
children with disabilities, applicable federal and state laws will be followed.
3.3 A written policy which sets out procedures for reporting incidents to police authorities,
parents,
guardians or Relative Caregivers and to the Department of Education, while maintaining
confidentiality.
3.4 A written policy on how evidence is to be kept, stored and documented, so that the chain
of custody is
clearly established prior to giving such evidence over to the police.
3.5 A written policy on search and seizure.
3.6 A program of assistance for students with counseling and referral to services as needed.
3.7 A discipline policy which contains, at a minimum, the following penalties for infractions
of state and
district drug policies.
3.7.1 Use/Impairment: For a first offense, if a student is found to be only impaired and not in
violation of any other policies, he/she shall be suspended for up to 10 days, or placed in an
alternative setting for up to 10 days, depending upon the degree of impairment, the nature
of
the substance used, and other aggravating or mitigating factors. For a second or subsequent
offense, a student may be expelled or placed in an alternative setting for the rest of the
school
year.
3.7.2 Possession of alcohol, a drug, a drug like substance, and/or a look alike substance, in
an
amount typical for personal use, and drug paraphernalia: For a first offense, the student
shall
be suspended for 5 to 10 days. For a second or subsequent offense, a student may be
expelled
for the rest of the school year or placed in an alternative setting for the rest of the school
year.

Section A - 25 - 7-2007
3.7.3 Possession of a quantity of alcohol, a drug, a drug like substance, a look alike
substance and
drug paraphernalia in an amount which exceeds an amount typical for personal use, or
distribution of the above named substances or paraphernalia: the student shall be
suspended
for 10 days, or placed in an alternative setting for 10 days. Depending on the nature of the

32

substance, the quantity of the substance and/or other aggravating or mitigating factors, the
student also may be expelled.
3.8 A policy in cases involving a drug like substance or a look alike substance for
establishing that the
student intended to use, possess or distribute the substance as a drug.
3.9 A policy which establishes how prescription and non-prescription drugs shall be handled
in the school
environment and when they will be considered unauthorized and subject to these state and
local
policies.
3.10 A policy which sets out the conditions for return after expulsion for alcohol or drug
infractions.
3.11 Notwithstanding any of the foregoing to the contrary, all policies adopted by public
school districts
relating to the possession or use of drugs shall permit a student's discretionary use and
possession of an
asthmatic quick relief inhaler ("Inhaler") or autoinjectable epinephrine with individual
prescription
label; provided, nevertheless, that the student uses the inhaler or autoinjectable epinephrine
pursuant to
prescription or written direction from a state licensed health care practitioner; a copy of
which shall be
provided to the school district; and further provided that the parent(s) or legal custodian(s)
of such
student provide the school district with written authorization for the student to possess and
use the
inhaler or autoinjectable epinephrine at such student's discretion, together with a form of
release
satisfactory to the school district releasing the school district and its employees from any
and all
liability resulting or arising from the student's discretionary use and possession of the
inhaler or
autoinjectable epinephrine and further provided that the school nurse may impose
reasonable
limitations or restrictions upon the student's use and possession of the inhaler or
autoinjectable
epinephrine based upon the student's age, level of maturity, behavior, or other relevant
considerations.
(For students who use prescribed asthmatic quick relief inhalers or autoinjectable
epinephrine, see 14 DE Admin. Code
817, Administration of Medications and Treatments)

618 School Safety Audit
1.0 Required School Safety Audit
Each school year every Delaware public school including Charter Schools and Alternative
Schools shall
conduct a School Safety Audit. Such audit shall be conducted using guidelines provided by
the Department of
Education. Districts and heads of charter schools shall ensure that a corrective plan of action
to address
identified needs is developed within sixty (60) days of the School Safety Audit. The
corrective plan of action
shall be made available to the Department of Education’s Quality Review Team at the time
of their visit.

620 School Crisis Response Plans
1.0 Required School Crisis Response Plan

33

Every Delaware public school including Charter Schools and Alternative Program sites shall
develop a School
Crisis Response Plan and shall conduct at least one practice drill annually. Following practice
drills, the
districts and heads of charter schools shall ensure that the school safety teams conduct
meetings to assess
readiness and determine the effectiveness of the existing plans. School Crisis Response
Plans shall be
developed using guidelines provided by the Department of Education and shall be made
available to the
Department of Education’s Quality Review Team at the time of their visit.

Section A - 26 - 7-2007
DELAWARE DEPARTMENT OF EDUCATION REGULATIONS
SECTION 900. SPECIAL POPULATIONS
901 Education of Homeless Children and Youth
1.0 Purpose
Consistent with the provisions of the McKinney-Vento Homeless Education Assistance
Improvement Act, as
amended by the No Child Left Behind Act of 2001 (42 U.S.C. §11431 et. seq.), the intent of
this regulation is to
ensure the educational rights and protections for children and youth experiencing
homelessness.
2.0 Definitions
The following words and terms, when used in this regulation, shall have the following
meaning unless the
context clearly states otherwise:
“Department” means the Delaware Department of Education.
“Homeless Children and Youths” as defined by the provisions of the 42 U.S.C. §11434a(2),
means
individuals who lack a fixed, regular, and adequate nighttime residence (within the meaning
of 42 U.S.C.
§11302(a)(1)); and includes:
Children and youths who are sharing the housing of other persons due to loss of housing,
economic
hardship or similar reason; are living in motels, hotels, trailer parks, or camping grounds due
to lack of
alternative adequate accommodations; are living in emergency or transitional shelters; are
abandoned in
hospitals; or are awaiting foster care placement;
Children and youths who have a primary nighttime residence that is in a private or public
place not
designed for or ordinarily used as a regular sleeping accommodation for human beings
(within the meaning of
42 U.S.C. §11302(a)(2)(C));
Children and youths who are living in cars, parks, public spaces, abandoned buildings,
substandard
housing, bus or train stations, or similar settings; and Migratory children (as such term is
defined in section
6399 of Title 20, the Elementary and Secondary Education Act of 1965) who qualify as
homeless because the
children are living in circumstances described above.
“LEA Homeless Liaison” means the Local Educational Liaison for Homeless Children and
Youths designated
under 42 U.S.C. §11432(g)(1)(J)(ii).

34

“Secretary” means the Secretary of Education.
“State Coordinator” means the Delaware Coordinator for Education of Homeless Children
and Youths
designated under 42 U.S.C. §11432(d)(3).
“Unaccompanied Youth” as defined by the provisions of 42 U.S.C. §11434a(6) includes a
youth not in the
company of a parent or guardian.
3.0 Federal Regulations
Local school districts shall comply with the provisions of the McKinney-Vento Homeless
Education Assistance
Improvement Act, as amended by the No Child Left Behind Act of 2001 (42 U.S.C. §11431 et.
seq.) and any
regulations issued pursuant thereto.
4.0 Procedures for the Resolution of Disputes Concerning the Educational Placement of
Homeless Children
and Youths
4.1 If a dispute arises over school selection or enrollment, the local school district must
immediately enroll
the homeless student in either the school of origin (as defined in 42 U.S.C. 11432(g)(3)(G))
or the
school that nonhomeless students who live in the attendance area in which the homeless
student is
actually living are eligible to attend, whichever is sought by the parent, guardian, Relative
Caregiver or
homeless youth, pending resolution of the dispute.
4.2 The local school shall provide the parent, guardian, Relative Caregiver or homeless youth
with a
written notice of the school’s decision regarding school selection or enrollment. The notice
shall
include:
4.2.1 A written explanation of the school’s decision regarding school selection or enrollment;
4.2.2 Contact information for the LEA Homeless Liaison and State Coordinator, with a brief
description of their roles;

Section A - 27 - 7-2007
4.2.3 A simple, detachable form that parents, guardians, Relative Caregiver or homeless
youth can
complete and turn into the school to initiate the dispute resolution process;
4.2.4 Instructions as to how to dispute the school’s decision at the district level;
4.2.5 Notice of the right to enroll immediately in the school of choice pending resolution of
the
dispute;
4.2.6 Notice that immediate enrollment includes full participation in all school activities for
which
the student is eligible;
4.2.7 Notice of the right to appeal to the State if the district level resolution is not
satisfactory; and
4.2.8 Time lines for resolving district and State level appeals.
4.3 District Level Dispute Resolution Process
4.3.1 Local school districts shall develop a dispute resolution process at the district level.
The
dispute resolution process shall be as informal and accessible as possible, but shall allow for
impartial and complete review. Parents, guardians, Relative Caregivers and homeless youth
shall be able to initiate the dispute resolution process directly at the school they choose or
the
school district or LEA Homeless Liaison’s office.

35

4.3.2 Within ten (10) calendar days of the initiation of the district level dispute resolution
process;
the school district shall inform the parties in writing of its determination, along with notice of
the right to appeal to the State if the district level resolution is not satisfactory.
4.4 Interdistrict Resolution Process
4.4.1 When interdistrict issues arise, including transportation, representatives from all
involved
school districts, the State Coordinator, or his or her designee, and the parent(s), guardian(s)
or
unaccompanied youth shall meet within ten (10) calendar days of the initiation of the
dispute
process to attempt to resolve the dispute.
4.4.2 The State Coordinator’s role is to facilitate the meeting.
4.4.3 If the parties are unable to resolve the interdistrict dispute, it shall be referred to the
Secretary
within ten (10) calendar days of the meeting. Subsection 4.5.4 through 4.5.9 shall govern
the
review official’s determination. The review official shall consider the entire record of the
dispute, including any written statements submitted and shall make a determination based
on
the child’s or youth’s best interest, as defined in 42 U.S.C. §11432(g)(3).
4.4.3.1 Notwithstanding 4.4.3, where the interdistrict dispute is limited solely to the issue of
the apportionment of responsibility and costs for providing the child transportation to
and from the school of origin, there shall be no referral to the Secretary. Pursuant to
42 USC 11432 (g)(1)(J)(iii)(II), if the school districts are unable to agree upon such a
method of appropriation, the responsibility for the costs for transportation shall be
shared equally.
4.5 State Level Dispute Resolution Process
4.5.1 The State level dispute resolution process is available for appeals from district-level
decisions
and interdistrict disputes. Appeals may be filed by parents, guardians, homeless youths or
school districts. Appeals filed by a local school shall not be accepted.
4.5.2 To initiate the State level dispute resolution process, the appellant must file a written
notice of
appeal with the Secretary no later than ten (10) calendar days after receiving written
notification of the district level or interdistrict decision. The notice of appeal shall state with
specificity the grounds of the appeal, and shall be signed by the appellant. Where the appeal
is being initiated by a school district, the superintendent of the district must sign the notice
of
appeal.
4.5.3 A copy of the notice of appeal shall be delivered by hand or certified mail to all other
parties
to the proceeding at the time it is sent to the Secretary. A copy of any other paper or
document filed with the Secretary or review official shall, at the time of filing, also be
provided to all other parties to the proceeding.
4.5.4 Upon receipt of a notice of appeal, the Secretary or his/her designee, shall within five
(5)
calendar days decide whether to hear the appeal or assign it to an independent and
impartial
review official and shall so advise the parties.
4.5.5 The local district shall file a certified record of the district or inter-district level dispute
proceeding with the Secretary or review official within five (5) calendar days of the date the
Secretary notifies the parties that an appeal has been filed. The record shall contain any
written decision, any written minutes of the meeting(s) at which the disputed action was

Section A - 28 - 7-2007
36

taken, all exhibits or documentation presented at the district or interdistrict level dispute
proceeding, and any other evidence relied on by the District(s) in making its (their) decision.
4.5.6 Appeals are limited to the record. The parties may support their positions in written
statements limited to matters in the existing record. In order to be considered, written
statements must be filed with the review official no later than twenty (20) calendar days
after
the appeal is filed.
4.5.7 The review official shall consider the entire record of the dispute, including any written
statements submitted in reaching his or her decision. The review official shall overturn the
district or interdistrict decision only if he or she decides that the district’s decision was not
supported by substantial evidence or was arbitrary or capacious or is inconsistent with state
and federal law or regulation.
4.5.8 Within thirty (30) calendar days of the receipt of the notice of appeal, the review
official shall
inform the parties of his or her determination.
4.5.9 The determination of the review official shall be final and is not subject to further
appeal
within the Department of Education.

925 Children with Disabilities
930 Supportive Instruction (Homebound)
1.0 Definition
“Supportive Instruction” is an alternative educational program provided at home, in a
hospital or at a related
site for students temporarily at home or hospitalized for a sudden illness, injury, episodic
flare up of a chronic
condition or accident considered to be of a temporary nature.
1.1 Procedures for eligibility shall be limited to appropriate certification that the student
cannot attend
school.
1.2 Services for children with disabilities as defined in the Individuals with Disabilities Act
(IDEA) and
the State Department of Education’s regulations on Children with Disabilities shall be
provided
according to the Administrative Manual: Special Education Services, and shall be processed
under the
district’s special education authority. Nothing in this regulation shall prevent a district from
providing
supportive instruction to children with disabilities in a manner consistent with the Individuals
with
Disabilities Education Act (IDEA) and the Administrative Manual.
1.3 Nothing in this regulation shall alter a district’s duties under Section 504 of the
Rehabilitation Act of
1973 or the Americans with Disabilities Act to students who are qualified individuals with
disabilities.
Nothing in this regulation shall prevent a district from providing supportive instruction to
such
students.
2.0 Eligibility
A student enrolled in a school district is eligible for supportive instruction when the school
receives the required
certification that an accident, injury, sudden illness or episodic flare up of a chronic condition
will prevent the
student from attending school for at least ten (10) school days.
2.1 A physician must certify absences due to a medical condition.

37

2.2 Absences due to severe adjustment problems must be certified by a psychologist or
psychiatrist and
confirmed through a staff conference.
2.3 A physician must certify absences due to pregnancy complicated by illness or other
abnormal
conditions.
2.3.1 Students do not qualify for supportive instruction for normal pregnancies unless there
are
complications.
2.3.2 Students who remain enrolled in school are eligible for supportive instruction during a
postpartum period not to exceed six weeks. Postpartum absences must be certified by a
physician.
2.4 Supportive instruction can be requested as an in school transitional program that follows
a period of
supportive instruction that was provided outside of the school setting. If the supportive
instruction is
provided as an in school transitional program, it must be approved through a staff
conference.
3.0 Implementation

Section A - 29 - 7-2007
Supportive instruction for students shall begin as soon as the documentation required by 2.0
is received.
Supportive instruction may continue upon the return to school setting only in those
exceptional cases where it is
determined that a student needs a transitional program to guarantee a successful return to
the school program as
delineated in 2.4.
1.1 Supportive instruction shall adhere to the extent possible to the student’s school
curriculum and shall
make full use of the available technology in order to facilitate the instruction.
1.1.1 The school shall provide a minimum of 3 hours of supportive instruction each week of
eligibility for students K to 5th grade, and a minimum of five hours each week of eligibility for
students 6 to 12th grade. There is no minimum for in school transition.
1.1.2 Nothing in this regulation shall prevent a school district from providing additional hours
of
supportive instruction to eligible students from either its Academic Excellence allotment or
other available funding sources.
3.2 Summer instruction is permitted for a student who is otherwise eligible for supportive
instruction and
as determined by the student’s teachers and principal, needs the instruction to complete
course work or
to maintain a level of instruction in order to continue in a school program the following
school year.

Section A - 30 - 7-2007

II. LAWS/LEGAL OPINIONS
This section highlights some of the statutes with particular relevance to the
school
setting. In some instance the entire statue is not printed. The entire
legislation is
accessed (see links within text) to obtain the most current information. The
text is
current through June 2006.
38

The Delaware Code (i.e., laws) is available at
http://delcode.delaware.gov/index.shtml
Title 1 – General Provisions
Title 2 – Transportation
Title 3 – Agriculture
Title 4 – Alcoholic Liquors
Title 5 – Banking
Title 6 – Commerce and Trade
Title 7 – Conservation
Title 8 – Corporations
Title 9 – Counties
Title 10 – Courts and Judicial Procedures
Title 11 – Crimes and Criminal Procedure
Title 12 – Decedents’ Estates and fiduciary Relations
Title 13 – Domestic Relations
Title 14 – Education
Title 15 – Elections
Title 16 – Health and Safety
Title 17 – Highways
Title 18 – Insurance Code
Title 19 – Labor
Title 20 – Military and Civil Defense
Title 21 – Motor Vehicles
Title 22 – Municipalities
Title 23 – Navigation and Waters
Title 24 – Professions and Occupations
Title 25 – Property
Title 26 – Public Utilities
Title 27 – Religion
Title 28 – Sports and Amusements
Title 29 – State Government
Title 30 – State Taxes
Title 31 - Welfare

Section A - 31 - 7-2007
13 DELAWARE CODE
CHAPTER 7. PARENTS AND CHILDREN1
Subchapter I. General Provisions

§ 701. Rights and responsibilities of parents; guardian appointment.
§ 702. [Repealed]
§ 703. Services and earnings of minor child.
§ 704 Action for loss of wages or services of minor child.
§ 705 [Repealed]
§ 706 [Repealed]
§ 707 Consent to health care of minors.
§ 708 Affidavit of Establishment of Power to Consent to Medical Treatment of Minors
§ 709 Consent of a minor to donate blood voluntarily without the necessity of obtaining parental
permission or authorization.
§ 710. Minor’s consent to diagnostic and lawful therapeutic procedures relating to care and treatment
for pregnancy or
contagious diseases.

__________
§ 701. Rights and responsibilities of parents; guardian appointment.
(a) The father and mother are the joint natural custodians of their minor child and are
equally charged with the child’s
support, care, nurture, welfare and education. Each has equal powers and duties with
respect to such child, and

39

neither has any right, or presumption of right or fitness, superior to the right of the other
concerning such child’s
custody or any other matter affecting the child. If either parent should die, or abandon his or
her family, or is
incapable, for any reason, to act as guardian of such child, then, the custody of such child
devolves upon the other
parent. Where the parents live apart, the Court may award the custody of their minor child
to either of them and
neither shall benefit from any presumption of being better suited for such award.
(b) This section shall not affect the laws of this State relative to the appointment of a
guardian of the property of a
minor, or the appointment of a third person as a guardian of the person of the minor where
the parents are
unsuitable or where the child’s interests would be adversely affected by remaining under the
natural guardianship
of his or her parents or parent.
(c) Any child who is the subject of a custody, visitation, guardianship, termination of parental
rights, adoption or
other related proceeding in which the Division of Family Services is a party should have a
guardian ad litem
appointed by the Court to represent the best interests of the child. The Court, in its
discretion, may also appoint
an attorney to represent the child's wishes. The guardian ad litem shall be an attorney
authorized to practice law
in the State or a Court-Appointed Special Advocate. The rights, responsibilities and duties of
the attorney serving
as guardian ad litem are set forth in section 9007A of Title 29, and the rights, responsibilities
and duties of the
Court-Appointed Special Advocate serving as guardian ad litem are set forth in Chapter 36 of
Title 31. When
determining whether to appoint an attorney through the Office of the Child Advocate or a
Court-Appointed
Special Advocate through the Family Court, the Family Court judge, in his or her discretion,
should assign the
most complex and serious cases to the Office of the Child Advocate.
§707. Consent to health care of minors.
(a) Definitions. As used in this section:
(1) “Medical treatment” means developmental screening, mental health screening and
treatment, and
ordinary and necessary medical and dental examination and treatment, including blood
testing, preventive
care including ordinary immunizations, tuberculin testing and well-child care. Medical
treatment also
means the examination and treatment of any laceration, fracture or other traumatic injury,
or any symptom,
disease or pathology which may, in the judgment of the treating health care professional, if
left untreated,
reasonably be expected to threaten health or life.
(2) “Blood testing” includes Early Periodic Screening, Diagnosis, and Treatment (EPSDT)
testing and other
blood testing deemed necessary by documented history or symptomatology but excludes
HIV/AIDS testing
and controlled substance testing or any other testing for which separate court order or
informed consent as
provided by law is required.

40

1

Refer to Delaware Code for complete text.

Section A - 32 - 7-2007
(3) “Relative caregiver” or “caregiver” means an adult person, who by blood, marriage or
adoption, is the
great grandparent, grandparent, step grandparent, great aunt, aunt, great uncle, uncle,
stepparent, brother,
sister, step brother, step sister, half brother, half sister, niece, nephew, first cousin or first
cousin once
removed of a minor and with whom the minor resides, but who is not the legal custodian or
guardian of the
minor.
(b) Parties authorized to give consent. Consent to the performance upon or for any minor by
any licensed medical,
surgical, dental, psychological or osteopathic practitioner or any nurse practitioner/clinical
nurse specialist or any
hospital or public clinic or their agents or employees of any lawful medical treatment, and to
the furnishing of
hospitalization and other reasonably necessary care in connection therewith, may be given
by:
(1) A parent or guardian of any minor for such minor;
(2) A married minor for himself or herself or, if such married minor be unable to give consent
by reason of
disability, then by his or her spouse;
(3) A minor of the age of 18 years or more for himself or herself;
(4) A minor parent for his or her child;
(5) A minor or by any person professing to be serving as temporary custodian of such minor
at the request of a
parent or guardian of such minor for the examination and treatment of (i) any laceration,
fracture or other
traumatic injury suffered by such minor, or (ii) any symptom, disease or pathology which
may, in the
judgment of the attending personnel preparing such treatment, if untreated, reasonably be
expected to
threaten the health or life of such minor; provided, however, that the consent given shall be
effective only
after reasonable efforts shall have been made to obtain the consent of the parent or
guardian of said minor;
or
(6) A relative caregiver acting pursuant to an Affidavit of Establishment of Power to Relative
Caregivers to
Consent to Medical Treatment of Minors.
(c) Effect of consent. Any consent given by or for a minor pursuant to the authority of any
provision of this chapter
shall be valid and effective for all purposes, and, notwithstanding any misrepresentation as
to age, status as parent,
guardian or custodian or as to marital status, made to any practitioner, hospital or clinic for
purposes of inducing
the furnishing of health care to such minor, shall bind such minor, his or her parent, spouse,
heirs, executors and
administrators and shall not be subject to subsequent disaffirmance by reason of minority.
(d) Liability of persons responsible for medical care. Nothing contained in this section shall
be construed to relieve
any practitioner, hospital, clinic or their agents or employees from liability for negligence in
diagnosis, care and

41

treatment or for the performance of any procedure not reasonably required for the
preservation of life or health.
§708. Affidavit of Establishment of Power to Consent to Medical Treatment of Minors.
(a) There is created an Affidavit of Establishment of Power to Relative Caregivers to Consent
to Medical Treatment
of Minors. The affidavit shall include, at a minimum, the name and date of birth of the minor;
a statement signed
by the caregiver that the caregiver is 18 years of age or older and that the minor resides
with the caregiver; the
names and signatures of the parents, legal custodian or guardian of the minor indicating
their approval of the
caregiver’s power or, if a parent, custodian or guardian of the minor is unavailable, a
statement of reasonable
effort made by the caregiver to locate the parent, custodian or guardian based on criteria
set forth in the
regulations; the name of the caregiver; relationship of the caregiver to the minor
documented by proof as defined
by regulation; and the dated signature of the caregiver. The signature of the caregiver shall
be notarized.
(b) The affidavit is valid for 1 year unless the minor no longer resides in the caregiver’s
home or a parent, custodian
or guardian revokes his or her approval. If a parent, custodian or guardian revokes approval,
the caregiver shall
notify any health care provider or health service plans with which the minor has been
involved through the
caregiver.
(c) A caregiver must present a completed Affidavit of Establishment of Power to Relative
Caregivers to Consent to
Medical Treatment of Minor when seeking medical treatment for a minor.
(d) The decision of a relative caregiver to consent to or to refuse medical treatment for a
minor shall be superseded by
a decision of a parent, legal custodian or guardian of the minor.
(e) No person who relies in good faith upon a fully executed Affidavit of Establishment of
Power to Relative
Caregivers to Consent to Medical Treatment of Minors in providing medical treatment shall
be subject to criminal
or civil liability or to professional disciplinary action because of the reliance. This immunity
applies even if
medical treatment is provided to a minor in contravention of a decision of a parent, legal
custodian or guardian of
the minor who signed the affidavit if the person providing care has no actual knowledge of
the decision of the
parent, or legal custodian or guardian.

Section A - 33 - 7-2007
(f) The decision of a relative caregiver, based upon an Affidavit of Establishment Power to
Relative Caregivers to
Consent to Medical Treatment of Minors, shall be honored by a health care facility or
practitioner unless the
health care facility or practitioner has actual knowledge that a parent, legal custodian or
guardian of a minor has
made a contravening decision to consent to or to refuse medical treatment for the minor.
(g) A person who knowingly makes a false statement in an affidavit under this section shall
be subject to a civil
penalty of $1,000 per child. Justices of the Peace shall have jurisdiction of these cases.

42

(h) The Department of Health and Social Services is authorized to promulgate regulations to
implement this section.
§709. Consent of a Minor to Donate Blood Voluntarily Without the Necessity of Obtaining
Parental
Permission or Authorization
(a) Anything otherwise provided in the law to the contrary notwithstanding, any person over
17 years old shall be
eligible to donate blood in any voluntary and noncompensatory blood program without
parental permission or
authorization.
(b) The consent given by a minor under this section shall, notwithstanding his or her
minority, be valid and legally
effective for all purposes and shall be binding upon such minor, his or her parents, legal
guardians, spouse, heirs,
executors and administrators as effectively as if such minor were 18 years of age or over at
the time of giving such
consent. A minor giving such consent shall be deemed to have the same legal capacity to
act and the same legal
obligations with regard to giving such consent as if such minor were 18 years of age or over.
Consent so given
shall not be subject to later disaffirmance by reason of such minority and the consent of no
other person or court
shall be necessary for performance of the lawful procedures required to be performed in
order to receive such
donation.
(c) Such consent so given by a minor as described above shall be interpreted as a contract
permitting penetration of
tissue which is necessary to accomplish such donation.
§710. Minors’ Consent to Diagnostic and Lawful Therapeutic Procedures Relating to Care and
Treatment
for Pregnancy or Contagious Diseases
(a) A minor 12 years of age or over who professes to be either pregnant or afflicted with
contagious, infectious or
communicable diseases within the meaning of Chapters 5 and 7 of Title 16, or who professes
to be exposed to the
chance of becoming pregnant, may give written consent, except to abortion, to any licensed
physician, hospital or
public clinic for any diagnostic, preventive, lawful therapeutic procedures, medical or
surgical care and treatment,
including X rays, by any physician licensed for the practice of medicine or surgery or
osteopathic medicine or
surgery in this State and by any hospital or public clinic, their qualified employees or agents
while acting within
the scope of their employment.
(b) Consent so given by a minor 12 years of age or over shall, notwithstanding his or her
minority, be valid and
legally effective for all purposes, regardless of whether such minor’s profession of pregnancy
or contagious
disease is subsequently medically confirmed, and shall be binding upon such minor, his or
her parents, legal
guardians, spouse, heirs, executors and administrators as effectively as if the minor were of
full legal age at the
time of giving of the consent. A minor giving the consent shall be deemed to have the same
legal capacity to act

43

and the same legal obligations with regard to giving consent as if the minor were of full legal
age. Consent so
given shall not be subject to later disaffirmance by reason of such minority; and the consent
of no other person or
court shall be necessary for the performance of the diagnostic and lawful therapeutic
procedures, medical or
surgical care and treatment rendered such minor.
(c) The physician licensed for the practice of medicine or surgery or hospital to whom such
consent shall be given
may, in the sole exercise of his, her or its discretion, either provide or withhold from the
parents or legal guardian
or spouse of such minor such information as to diagnosis, therapeutic procedures, care and
treatment rendered or
to be rendered the minor as such physician, surgeon or hospital deems to be advisable
under the circumstances,
having primary regard for the interests of the minor.
(d) The parents, legal guardian or spouse of a consenting minor shall not be liable for
payment for diagnostic and
lawful therapeutic procedures performed, medical or surgical care or treatment rendered or
hospital confinement
pursuant to this section.
(e) Notice of intention to perform any operation otherwise permitted under this section shall
be given the parents or
legal guardian of such minor at their last known address, if available, by telegram sent at
time of diagnosis by the
surgeon designated to perform such operation; provided, that such operation may proceed
forthwith after

Section A - 34 - 7-2007
diagnosis if there is reason to believe that delay would endanger the life of such minor or
there is a reasonable
probability of irreparable injury.
(f) Nothing contained in this section shall be construed to relieve any licensed physician,
hospital or public clinic,
their agents or employees, from liability for their negligence in the diagnosis, care and
treatment rendered such
minor.

14 DELAWARE CODE
CHAPTER 1. DEPARTMENT OF EDUCATION1
Subchapter II. Powers and Duties
§131. Public school enrollees’ immunization program; exemptions
(a) The Department shall from time to time, with advice from the Division of Public Health,
adopt and promulgate
rules and regulations to establish an immunization program to protect pupils enrolled in
public schools from
certain diseases. Such rules and regulations shall include at least the following:
(1) The designation of a basic series of immunizations to be administered according to these
rules;
(2) The requirement that all persons enrolling in the public schools at any age or level as
authorized by this
title shall have:
a. Been immunized according to the required program prior to the time of enrollment in the
Delaware schools;
b. Begun the series of immunizations not later than the time of enrollment to be completed
within a reasonable time as prescribed by the Department in relation to the particular
immunization involved; or

44

c. Presented written documentation of any claim of prior immunization in the form of a
statement from the immunizing physician or agency or such other form as may from time to
time be approved by regulation of the Department;
(3) Provision that persons seeking to be enrollees of the public school who have not been
immunized or do
not meet the requirements for immunization within the time prescribed shall be denied
further
attendance in the public schools;
(4) Provision for written notification of the parent, or legal guardian of an enrollee, of a
pending exclusion;
(5) Provision for exemption from any or all of the immunization program prescribed for a
particular
enrollee upon a written statement from a physician, i.e., medical doctor or doctor of
osteopathy, stating
that the enrollee should not receive the prescribed immunization or immunizations required
in the basic
series because of the reasonable certainty of a reaction detrimental to that person. A history
of clinical
illness of measles or rubella shall not be accepted as cause for exemption;
(6) Provision for exemption from the immunization program for an enrollee whose parents or
legal
guardian, because of individual religious beliefs, reject the concept of immunization. Such a
request
for exemption shall be supported by the affidavit herein set forth:
AFFIDAVIT OF RELIGIOUS BELIEF
STATE OF DELAWARE
………. COUNTY
1. (I) (We) (am) (are) the (parent[s]) (legal guardian[s]) of .
Name of Child
2. (I) (We) hereby (swear) (affirm) that (I) (we) subscribe to a belief in a relation to a
Supreme Being involving
duties superior to those arising from any human relation.
3. (I) (We) further (swear) (affirm) that our belief is sincere and meaningful and occupies a
place in (my) (our) life
parallel to that filled by the orthodox belief in God.
4. This belief is not a political, sociological or philosophical view of a merely personal moral
code.
1 Refer to Delaware Code for complete text.

Section A - 35 - 7-2007
5. This belief causes (me) (us) to request an exemption from the mandatory school
vaccination program for
.
Name of Child
Signature of Parent(s) or Legal Guardian(s)
SWORN TO AND SUBSCRIBED before me, a registered Notary Public, this day of , 2 .
(Seal)
Notary Public
My commission expires:
(7) Provision that, in the event that the Division of Public Health of the Department of Health
and Social
Services declares that there is throughout the State or in a particular definable region of the
State an
epidemic of a vaccine preventable disease, any child who is enrolled in a public school and
who has

45

been exempt from the immunization program for any of the causes authorized herein shall
be
temporarily excluded from attendance at a public school. Rules and regulations of the
Department
shall provide that in the event of such temporary exclusion, it will be the responsibility of the
school
and the parents or legal guardian of the enrollee to assist him or her in keeping up with his
or her
school work and that no academic penalty shall be suffered by the enrollee upon return to
school if the
student has maintained his or her relationship with the school through the assignments
prescribed. An
enrollee so temporarily excluded shall be authorized to return to school upon the lifting by
the Division
of Public Health of the epidemic declaration;
(8) Provision that in any situation where the parents or legal guardian of the enrollee states
that he or she
has been immunized, but that the record has been lost or destroyed by the provider of the
immunizations, the following procedure may be carried out by that responsible person and
shall be
accepted by the local school district board of education or its designee in lieu of compliance
with the
immunization requirement:
a. The responsible person, or the school nurse, shall sign a statement that the record of the
enrollee’s immunization has been lost; and
b. The responsible person shall be responsible for the enrollee obtaining one (1) dose of
each of
the vaccines prescribed in the basic series of immunization;
(9) Provision for an enrollee who has reached the statutory age of majority set by laws for
the State to be
responsible for his or her immunization program and for execution of the request for
religious
exemption herein authorized;
(10) Provision that it shall be the responsibility of each Delaware public school district to
administer, or
prescribe a designee to administer, rules and regulations herein authorized and promulgated
by the
Department of Education.
(b) Appeals from the decision of the Department rendered pursuant to this section shall be
to the Superior Court
and shall be made in the same manner as is provided by the Superior Court Civil Rules for
appeals from
commissions, boards and agencies. Such appeal shall be on the record before the
Department.

14 DELAWARE CODE
CHAPTER 2. THE PUBLIC SCHOOL SYSTEM1
Subchapter I. System of Free Public Schools
§202. Free schools; ages; attendance within school district; nonresidents of Delaware
1 Refer to Delaware Code for complete text.

Section A - 36 - 7-2007
NOTE: “Caregiver’s Law begins at (e) (2) c.
(a) The public schools of this State shall be free to persons who are residents of this State
and who are age 5 years
through 20 years inclusive when they are attending kindergarten through grade 12.

46

(b) The public schools of any school district which maintains schools established under § 203
or § 204 of this title for
persons below the age of 5 years shall be free to persons who are residents of such school
district and who have
attained the specified age below the age of 5 years for which such schools are established.
(c) Persons attending the public schools of this State shall attend the public schools in the
school district within which
they reside, except as provided in Chapters 4, 5 and 6 of this title and in Chapter 92, Volume
23, Laws of Delaware,
as amended by Chapter 172, Volume 55, Laws of Delaware. Notwithstanding the foregoing,
homeless children and
unaccompanied youth, as defined by 42 U.S.C. §11434a, shall attend school in accordance
with the McKinneyVento Homeless Education Assistance Improvement Act >42 U.S.C. §§11431 to 11435;
provided any person
determined to be ineligible under the act may be denied enrollment. For the purpose of this
section and provisions
of the McKinney-Vento Homeless Education Assistance Improvement Act [42 U.S.C. §§11431
to 11435], the words
“awaiting foster care placement” include all children in foster care.
(d) Persons who are nonresidents of this State may attend the public schools of this State
under such terms and
conditions as may be otherwise provided by law.
(e) (1) For purposes of this section, a student shall be considered a resident of the school
district in which his or her
parents or legal guardian resides. If the child's parents do not reside together and a court of
appropriate
jurisdiction has entered a custody order, the child's residency for school attendance
purposes shall be
determined as follows unless otherwise agreed in a writing signed by both parents:
a. In cases in which 1 parent is awarded sole custody, the child shall be considered a
resident of the district in
which the sole custodian resides.
b. In cases in which the parents are granted joint custody, the child shall be considered a
resident of the
district in which the primary residential parent resides.
c. In cases in which the parents are granted shared custody, the child may be considered a
resident of either
parent's district.
Under no circumstances shall a child be enrolled in 2 different schools at the same time.
(2) If a child seeks to be considered a resident of a particular school district based on the
residence of anyone other
than his or her parent(s) or legal guardian, the student must have:
a. A signed order from a court of appropriate jurisdiction granting custody to or appointing
as the child's
guardian the resident with whom he or she is residing; or
b. Suitable documentation certifying that the child resides within the district by action of the
State or approval
by the school district to be considered the student's residence; or
c. A completed and notarized Establishment of Delegation of Power to Relative Caregivers to
Consent for
Registering Minors for School (also known as "Caregivers School Authorization") pursuant to
subsection
(f) of this section confirming a caregiver's ability to provide consent in those cases where the
student is

47

being cared for by an adult relative caregiver without legal custody or guardianship.
(3) Children under the care or custody of the Department of Services for Children, Youth and
Their Families are
exempted from the provisions of this subsection. Children in the care or custody of the
Department of Services
for Children, Youth and Their Families who are in foster care shall attend school in
accordance with the
McKinney-Vento Homeless Education Assistance Act (42 U.S.C. 11431 to 11435).
(f) (1) A child may be enrolled in a particular school district based upon the submission of a
Caregivers School
Authorization if the following conditions are satisfied:
a. The child resides with a relative caregiver who is 18 years of age or older, is a Delaware
resident, and
resides in the district in which the child seeks enrollment;
b. The child resides with the relative caregiver as a result of:
1. The death, serious illness, incarceration or military assignment of a parent or legal
guardian;
2. The failure or inability of the parent or legal guardian to provide substantial financial
support or
parental care or guidance;
3. Alleged abuse or neglect by the parent, legal guardian or others in the parent or legal
guardian's
residence;
4. The physical or mental condition of the parent or legal guardian which prevents adequate
care and
supervision of the child;
5. The loss or uninhabitability of the student's home as the result of a natural disaster; or
6. Other circumstances as deemed appropriate by the school district;

Section A - 37 - 7-2007
c. The child is not currently subject to an expulsion from school (as set forth in § 4130 of this
title) or
suspended from school for conduct that could lead to expulsion;
d. The child's residency with the caregiver is not for the purpose of:
1. Attending a particular school (although a caregiver's school district may be considered
when deciding
placement of the child as between 2 or more relative caregivers);
2. Circumventing the Enrollment Choice Program (Chapter 4 of this title);
3. Participating in athletics at a particular school;
4. Taking advantage of special services or programs offered at a particular school; or
5. Other similar purposes; and
e. The caregiver submits to the school district in which the child seeks enrollment a
completed and notarized
Caregivers School Authorization using the most recent form developed for this purpose by
the Department
of Health and Social Services. The Caregivers School Authorization must include the
following:
1. The name and date of birth of the child;
2. The name, address and date of birth of the caregiver;
3. The names of the child's mother, father, legal custodian or guardian;
4. Relationship of the caregiver to the child, documented by proof of relationship as defined
by
regulation;
5. A statement that the caregiver has full-time care of the student, documented as required
by regulation;

48

6. A statement indicating which of the circumstances described in subparagraph (b) of this
paragraph
applies;
7. A statement that the caregiver will be the person responsible for enrolling the student in
school, being
the legal contact for the school, and making school-based medical and special education
decisions;
8. The notarized and dated signatures of the caregiver, parents, legal custodians or
guardians, including a
sworn statement of the accuracy of the information provided and confirming that the
caregiver and
other signatories are aware of the penalties for falsely completing the Authorization. If after
a
reasonable effort the caregiver is unable to locate the parents, then as an alternative to
including the
parents' signatures, the Authorization shall include a statement of reasonable efforts made
to locate the
parents;
9. If available, any custody order in effect regarding the child. The order shall be submitted
as an
attachment to the Caregivers School Authorization and shall include only that portion of the
order
indicating to whom custody is granted.
If the documentation required to verify the information in the Caregivers School
Authorization cannot be
obtained by the caregiver, then the schools shall permit the child to enroll provided that a
custody or
guardianship petition that is date stamped to indicate that it has been filed with Family Court
is provided
within 10 business days of enrollment. Additional time for submission of the date stamped
petition may be
provided as deemed appropriate by the individual district. The petition shall permit
enrollment until the
end of the school year or until such time as the court enters a decision disposing of the
custody or
guardianship petition, whichever first occurs;
(2) A relative caregiver is an adult who by blood, marriage or adoption is the child's great
grandparent, grandparent,
stepgrandparent, great aunt, aunt, stepaunt, great uncle, uncle, stepuncle, stepparent,
brother, sister, stepbrother,
stepsister, half brother, half sister, niece, nephew, first cousin or first cousin once removed
but who does not
have legal custody or legal guardianship of the student.
(3) A caregiver who completes and submits a Caregivers School Authorization form to
register a child in his or her
care for school is authorized and agrees to act in the place of the parent or parents with
respect to the child's
education decisions (including but not limited to special education decisions) and the person
the school contacts
regarding truancy, discipline and school-based medical care. Once a Caregivers School
Authorization is
submitted and approved, school districts are no longer responsible, for so long as the
Authorization is valid, for
communicating with the parent, custodian or guardian who has signed the Authorization or
is listed as unable to

49

be found.
(4) A Caregivers School Authorization that complies with the requirements of this section
shall be honored by any
school in any school district. The school districts shall determine whether a particular
Caregivers School
Authorization complies with the requirements of this section. A caregiver may appeal the
school district's
decision to the local board of education of the school district. Any school district that
reasonably and in good
faith relies on a Caregivers School Authorization has no obligation to make any further
inquiry or investigation.

Section A - 38 - 7-2007
(5) Persons who knowingly make false statements in the Caregivers School Authorization
shall be subject to a
minimum civil penalty of $1000 and maximum of the average annual per student
expenditure and may be
required to reimburse the school district tuition costs. Further, such persons may be subject
to criminal
prosecution pursuant to § 1233 of Title 11. The Justices of the Peace shall have jurisdiction in
these cases.
(6) Caregivers School Authorizations filed prior to January 1 shall be honored for the balance
of the current school
year and for the subsequent school year. Caregivers School Authorizations filed on or after
January 1 shall be
honored for the balance of the current school year and for the 2 subsequent school years. In
either case, the
Authorization shall expire on August 1 of the applicable school year unless the caregiver
receives permission
from the school district to extend the length of time that the Authorization will be honored.
Caregivers School
Authorizations may be cancelled at anytime if the minor stops living with the relative
caregiver or upon written
revocation of the Authorization by the child's caregiver, parent, legal custodian or guardian.
(7) The Department of Health and Social Services shall be authorized to promulgate
regulations to implement this
law. This law shall take effect upon the promulgation of such regulations. Relationship and
proof of actual
full-time caregiving will be verified as stated in the regulations.

14 DELAWARE CODE
CHAPTER 13. SALARIES AND WORKING CONDITIONS OF SCHOOL
EMPLOYEES1
§1310. Salary schedules for school nurses
(a) All nurses who hold appropriate certificates shall be paid in accordance with §1305 of this
title effective July 1,
1979.
(b) A reorganized school district may employ personnel to be paid for 10 months per year
from state funds pursuant
to this section in a number equal to 1 for each 40 state units of pupils, except that in schools
for the physically
handicapped within the district the allocation shall be in accordance with the rules and
regulations adopted by the
Department with the approval of the State Board of Education; provided further, that each
reorganized school

50

district shall ensure that it has at least 1 school nurse per facility. To the extent that the
funding formula outlined
above does not provide for 1 school nurse per facility, each reorganized school district shall
meet this requirement
out of funding provided under §1707 or §1716 of the title, or out of discretionary local
current operating expense
funds. Districts shall qualify for partial funding at the rate of 30% of the fractional part of 40
state units of pupils.

14 DELAWARE CODE
CHAPTER 41. GENERAL REGULATORY PROVISIONS2
§4123. Child Abuse Detection; reporting training
(a) Each public school shall ensure that each full-time teacher receives 1 hour of training
every year in detection and
reporting of child abuse. This training, and all materials used in such training, shall be
prepared by the Division
of Family Services.
(b) Any in-service training required by this section shall be provided within the contracted
school year as provided in
§ 1305 (e) of this title.
§ 4123A. School bullying prevention and criminal youth gang detection training.
(a) Each school district and charter school shall ensure that its public school employees
receive combined training
each year totaling 1 hour in the identification and reporting of criminal youth gang activity
pursuant to § 617 of
Title 11 and bullying prevention pursuant to § 4112D of this title. The training materials shall
be prepared by the
Department of Justice and the Department of Education in collaboration with law
enforcement agencies, the
Delaware State Education Association, the Delaware School Boards Association and the
Delaware Association of
School Administrators.
1 Refer to Delaware Code for complete text.
2 Refer to Delaware Code for complete text.

Section A - 39 - 7-2007
(b) Any in-service training required by this section shall be provided within the contracted
school year as provided in
§ 1305(e) of this title. (76 Del. Laws, c. 14, § 1.)

16 DELAWARE CODE
CHAPTER 9. ABUSE OF CHILDREN1
Subchapter I. Reports and Investigations of Abuse and Neglect; Child Protection
Accountability Commission
§901. Purpose
§902. Definitions2
As used in this chapter, the following terms mean:
(1) “Abuse” shall mean any physical injury to a child by those responsible for the care,
custody and control of the
child, through unjustified force as defined in § 468 of Title 11, emotional abuse, torture,
criminally negligent
treatment, sexual abuse, exploitation, maltreatment or mistreatment.
(3) “Child” shall mean any person who has not reached his or her 18th birthday.
(4) “Child Protection Registry” or “Registry” means a collection of information as described in
subchapter II of
this chapter about persons who have been substantiated for abuse or neglect as provided in
Subchapter II of this

51

chapter or who were substantiated between August 1, 1994, and February 1, 2003.
(5) “Child welfare proceeding” means any Family Court proceeding and subsequent appeal
therefrom involving
custody, visitation, guardianship, termination of parental rights, adoption or other related
petitions that involve a
dependent, neglected or abused child or a child at risk of same as determined by the Family
Court.
(10) “Good faith” shall be presumed in the absence of evidence of malice or willful
misconduct.
(13) “Neglect” shall mean the failure to provide, by those responsible for the care, custody
and control of the child, the
proper or necessary: Education as required by law; nutrition; or medical, surgical or any
other care necessary for
the child’s well-being.
(17) “Those responsible for the care, custody, and control of the child” shall include, but not
be limited to, the
parents or guardian of the child, other members of the child’s household, adults within the
household who have
responsibility for the child’s well-being, persons who have temporary responsibility for the
child’s well being, or a
custodian as that term is defined by § 901(6) of Title 10.
§903. Reports required
Any physician, and any other person in the healing arts including any person licensed to
render services in medicine,
osteopathy, dentistry, any intern, resident, nurse, school employee, social worker,
psychologist, medical examiner or any
other person who knows or in good faith suspects child abuse or neglect shall make a report
in accordance with § 904 of
this title. In addition to and not in lieu of reporting to the Division of Family Services, any
such person may also give
oral or written notification of said knowledge or suspicion to any police officer who is in the
presence of such person for
the purpose of rendering assistance to the child in question or investigating the cause of the
child’s injuries or condition.
§904. Nature and content of report; to whom made.
Any report required to be made under this chapter shall be made to the Division of Child
Protective Services of the
Department of Services for Children, Youth and Their Families. An immediate oral report shall
be made by telephone or
otherwise. Reports and the contents thereof including a written report, if requested, shall be
made in accordance with the
rules and regulations of the Division of Child Protective Services, or in accordance with the
rules and regulations
adopted by the Division.
§907. Temporary emergency protective custody
1 Refer to Delaware Code for complete text.
2 Refer to Delaware Code for definitions not included.

Section A - 40 - 7-2007
§ 907A. Safe Arms for Babies.
(a) The General Assembly finds and declares that the abandonment of a baby is an
irresponsible act by parent(s)
and places the baby at risk of injury or death from exposure, actions by other individuals,
and harm from
animals. However, the General Assembly does recognize that delivering a live baby to a safe
place is far

52

preferable to a baby killed or abandoned by the parent(s). The General Assembly further
finds and declares that
the purpose of this section is not to circumvent the responsible action of parent(s) who
adhere to the current
process of placing the baby for adoption, but to prevent the unnecessary risk of harm to or
death of that baby by
desperate parent(s) who would otherwise abandon or cause the death of that baby. The
General Assembly
further finds and declares that medical information about the baby and the baby's parent(s)
is critical for the
adoptive parents and that every effort should be made, without risking the safe placement
of the baby, to obtain
that medical information and provide counseling information to those parent(s). The General
Assembly further
finds and declares that if this section does not result in the safe placement of such babies or
is abused by
parent(s) attempting to circumvent the current process of adoption, it should be repealed.
(b) A person may voluntarily surrender a baby directly to an employee or volunteer of the
emergency department of
a Delaware hospital inside of the emergency department, provided that said baby is
surrendered alive, unharmed
and in a safe place therein.
(c) A Delaware hospital shall be authorized to take temporary emergency protective custody
of the baby who is
surrendered pursuant to this section. The person who surrenders the baby shall not be
required to provide any
information pertaining to his or her identity, nor shall the hospital inquire as to same. If the
identity of the
person is known to the hospital, the hospital shall keep the identity confidential. However,
the hospital shall
either make reasonable efforts to directly obtain pertinent medical history information
pertaining to the baby
and the baby's family or attempt to provide the person with a postage paid medical history
information
questionnaire.
(d) The hospital shall attempt to provide the person leaving the baby with the following:
(1) Information about the Safe Arms program;
(2) Information about adoption and counseling services, including information that
confidential adoption
services are available and information about the benefits of engaging in a regular, voluntary
adoption process;
and
(3) Brochures with telephone numbers for public or private agencies that provide counseling
or adoption
services.
(e) The hospital shall attempt to provide the person surrendering the baby with the number
of the baby's
identification bracelet to aid in linking the person to the baby at a later date, if reunification
is sought. Such an
identification number is an identification aid only and does not permit the person possessing
the identification
number to take custody of the baby on demand.
(f) If a person possesses an identification number linking the person to a baby surrendered
at a hospital under this

53

section and parental rights have not already been terminated, possession of the
identification number creates a
presumption that the person has standing to participate in an action. Possession of the
identification number
does not create a presumption of maternity, paternity or custody.
(g) Any hospital taking a baby into temporary emergency protective custody pursuant to this
section shall
immediately notify the Division and the State Police of its actions. The Division shall obtain
ex parte custody
and physically appear at the hospital within 4 hours of notification under this subsection
unless there are exigent
circumstances. Immediately after being notified of the surrender, the State Police shall
submit an inquiry to the
Delaware Missing Children Information Clearinghouse.
(h) The Division shall notify the community that a baby has been abandoned and taken into
temporary emergency
protective custody by publishing notice to that effect in a newspaper of statewide
circulation. The notice must
be published at least 3 times over a 3-week period immediately following the surrender of
the baby unless the
Division has relinquished custody. The notice, at a minimum, shall contain the place, date
and time where the
baby was surrendered, the baby's sex, race, approximate age, identifying marks, any other
information the
Division deems necessary for the baby's identification, and a statement that such
abandonment shall be:
(1) The surrendering person's irrevocable consent to the termination of all parental rights, if
any, of such
person on the ground of abandonment; and
(2) The surrendering person's irrevocable waiver of any right to notice of or opportunity to
participate in any
termination of parental rights proceeding involving such child, unless such surrendering
person manifests an
intent to exercise parental rights and responsibilities within 30 days of such abandonment.

Section A - 41 - 7-2007
(i) When the person who surrenders a baby pursuant to this section manifests a desire to
remain anonymous, the
Division shall neither initiate nor conduct an investigation to determine the identity of such
person, and no court
shall order such an investigation unless there is good cause to suspect child abuse or
neglect other than the act
of surrendering such baby. (73 Del. Laws, c. 187, §§ 3, 8; 75 Del. Laws, c. 376, § 1.)
§908. Immunity from liability, and special reimbursement to hospitals for expenses related to
certain babies
(a) Anyone participating in good faith in the making of a report or notifying police officers
pursuant to this
chapter, performing a medical examination without the consent of those responsible for the
care, custody and control of a
child pursuant to § 906(b)(5) of this title, or exercising emergency protective custody in
compliance with § 907 of this
title, shall have immunity from any liability, civil or criminal, that might otherwise exist, and
such immunity shall extend
to participation in any judicial proceeding resulting from the above actions taken in good
faith. This section shall not

54

limit the liability of any health care provider for personal injury claims due to medical
negligence that occurs as a result
of any examination performed pursuant to § 906(b)(3) of this title.
§909. Privileged communication not recognized
No legally recognized privilege, except that between attorney and client and that between
priest and penitent in a
sacramental confession, shall apply to situations involving known or suspected child abuse,
neglect, exploitation or
abandonment and shall not constitute grounds for failure to report as required by §903 of
this title or to give or accept
evidence in any judicial proceeding relating to child abuse or neglect.
§913. Child under treatment by spiritual means not neglected.
No child who in good faith is under treatment solely by spiritual means through prayer in
accordance with the tenets and
practices of a recognized church or religious denomination by a duly accredited practitioner
thereof shall for that reason
alone be considered a neglected child for the purposes of this chapter.

16 DELAWARE CODE
CHAPTER 26. CHILDHOOD LEAD POISONING PREVENTION ACT
§ 2601. Short title.
This act shall be known and may be cited as the Childhood Lead Poisoning Prevention Act.
§ 2602. Physicians and health care facilities to screen children.
(a) Every health care provider who is the primary health care provider for a child shall order
screening of that child,
in accordance with standards promulgated by the Division of Public Health, at or around 12
months of age for
lead poisoning.
(b) For a child who is deemed by the primary health care provider, pursuant to guidelines
promulgated by the
Division of Public Health, to be at high risk for lead poisoning, that health care provider shall
order screening of
that child for lead poisoning in accordance with guidelines and criteria set forth by the
Division of Public Health.
(c) Unless the child is at high risk for lead poisoning, as determined by the primary health
care provider, pursuant to
guidelines promulgated by the Division of Public Health, screening shall not be required for
any child who is over
12 months of age on March 1, 1995.
(d) All laboratories involved in lead level analysis will participate in a universal reporting
system as established by
the Division of Public Health.
(e) Nothing in this section shall be construed to require any child to undergo a lead blood
level screening or test
whose parent or guardian objects on the grounds that the screening or test conflicts with the
parent's or guardian's
religious beliefs.
(f) All laboratories involved in blood lead level analysis will participate in a universal
reporting system as established
by the State Board of Health.

Section A - 42 - 7-2007
§ 2603. Screening prior to child care or school enrollment.
For every child born on or after March 1, 1995, and who has reached the age of 12 months,
child care facilities and
public and private nursery schools, preschools and kindergartens shall require screening for
lead poisoning for admission

55

or continued enrollment; except in the case of enrollment in kindergarten, such testing may
be done within 60 calendar
days of the date of enrollment. A statement shall be provided from the child's primary health
care provider that the child
has been screened for lead poisoning or in lieu thereof a certificate signed by the parent or
guardian stating that the
screening is contrary to that person's religious beliefs.
§ 2604. Reimbursement by third party payers.
Screening, screening-related services and diagnostic evaluations as required by §2602 of
this title shall be reimbursable
under health insurance contracts and group and blanket health insurance as provided by
Chapter 33 and Chapter 35,
respectively, of Title 18.
§ 2605. Childhood Lead Poisoning Advisory Committee.
(a) There is hereby established the Childhood Lead Poisoning Prevention Advisory Committee
to ensure the
implementation of the Childhood Lead Poisoning Prevention Act established pursuant to this
chapter and to make
any necessary recommendations for the implementation of the program or improvements of
the processes to be
followed by the agencies responsible for the implementation of said plan.
(b) The Committee shall semiannually prepare and distribute a report regarding the
Childhood Lead Poisoning
Prevention Act, the intervention activities, studies of incidence, the State Blood Lead
Screening Program, and
monitoring and implementation of regulations promulgated pursuant to this chapter.
(c) The Committee shall be cochaired by the Secretary of the Department of Health and
Social Services or the
Secretary's designee and the Secretary of Education or the Secretary's designee and shall
have no more than 7
members. The Secretary of Education and the Secretary of Health and Social Services shall,
after consultation
with the Governor, appoint 7 members comprised of individuals which shall include a
representative of the
Department of Services for Children, Youth and Their Families, which must represent the
interests of daycare
licensing, a representative of the medical community at large who is a practicing physician,
an administrative
representative of a school district, and a public member.
(d) The Committee will sunset upon full implementation of the Childhood Lead Poisoning
Prevention Act.

16 DELAWARE CODE
CHAPTER 30C. AUTOMATIC EXTERNAL DEFIBRILLATORS (AEDS)
§3001C. Findings and Purpose
The General Assembly of the State has found that each year more than 350,000 Americans
experience out-of-hospital
sudden cardiac arrest. More than 95% of them die. In many cases, people die because life
saving defibrillators arrive on
the scene too late, if at all. It is estimated that more than 100,000 deaths could be
prevented each year if defibrillators
were more widely available to designated users (responders). Many communities around the
country have invested in
911 emergency response systems, emergency personnel and ambulance vehicles. However,
many of these same

56

communities do not have enough defibrillators. It is therefore the intent of this General
Assembly to encourage greater
acquisition, deployment, and use of automated external defibrillators in communities within
the State.
§3002C. Definitions
The following words, terms and phrases, when used in this chapter, shall have the meanings
ascribed to them herein,
except where the context clearly indicates a different meaning:
(a) “Automated external defibrillator,” (AED) shall mean a medical device which is both a
heart monitor and
defibrillator that has received approval of its pre-market notification, filed with the Food and
Drug Administration
pursuant to United States Code, Title 21, section 360(k).

Section A - 43 - 7-2007
(b) “Records” shall mean the recordings of interviews and all oral or written reports,
statements, minutes,
memoranda, charts, statistics, data and other documentation generated by the State EMS
Medical Director.
§3003C. Correct use of defibrillator; training in order to ensure public health and safety
(a) Any entity to whom AEDs are distributed shall insure that:
(1) Each prospective defibrillator user receives appropriate training by the American Red
Cross, the American
Heart Association, Delaware State Fire School or by another nationally recognized provider of
training for
cardio-pulmonary resuscitation and AED use; provided however, that such training shall be
approved by
the State EMS Medical Director;
(2) The defibrillator is maintained and tested according to the manufacturer’s guidelines;
and
(3) Any person who renders emergency care or treatment on a person in cardiac arrest by
using an AED shall
notify the appropriate EMS units as soon as possible and report any clinical use of the AED to
the
appropriate licensed physician or medical authority.
(b) The State EMS Medical Director shall maintain a file containing the name of each person
or entity that acquires
an AED with State funding.
§ 3004C. Quality Review Program
All quality management proceedings shall be confidential. Records of the State EMS Medical
Director, and EMS
quality care review committee relating to AED reviews and audits shall be confidential and
privileged, are protected, and
are not subject to discovery, subpoena or admission into evidence in any judicial or
administrative proceeding. Raw data
used in any AED review or audit shall not be available for public inspection; nor is such raw
data a “public record” as set
forth in the Delaware Freedom of Information Act.
§3005C. Provision of limited liability protections
(a) Any person or entity, who in good faith and without compensation, renders emergency
care or treatment by the
use of an AED shall be immune from civil liability for any personal injury as a result of such
care or treatment, or
as a result of any act or failure to act in providing or arranging further medical treatment, if
such person acts as an

57

ordinary, reasonably prudent person would have acted under the same or similar
circumstances and such act or
acts do not amount to willful or wanton misconduct or gross negligence.
(b) Any individual who authorizes the purchase of an AED, any person or entity who provides
training in
cardiopulmonary resuscitation and the use of an AED, and any person or entity responsible
for the site where the
AED is located shall be immune from civil liability for any personal injury that results from
any act or omission
that does not amount to willful or wanton misconduct to gross negligence.

16 DELAWARE CODE
CHAPTER 68. EXEMPTIONS FROM CIVIL LIABILITY1

Subchapter I. Immunity for Rendering Emergency Care2
§ 6801. Persons rendering emergency care exempt from liability; Advanced Life Support
Standards
Committee. 3
(a) Notwithstanding any inconsistent provisions of any public or private and special law, any
person who voluntarily,
without the expectation of monetary or other compensation from the person aided or
treated, renders first aid,
emergency treatment or rescue assistance to a person who is unconscious, ill, injured or in
need of rescue
assistance, or any person in obvious physical distress or discomfort shall not be liable for
damages for injuries
alleged to have been sustained by such person or for damages for the death of such person
alleged to have
occurred by reason of an act or omission in the rendering of such first aid, emergency
treatment or rescue
1 Refer to Delaware Code for complete text.
2 Refer to Delaware Code for complete text.
3 Refer to Delaware Code for (b), which describes the Advanced Life Support Standards
Committee.

Section A - 44 - 7-2007
assistance, unless it is established that such injuries or such death were caused willfully,
wantonly or recklessly or
by gross negligence on the part of such person. This section shall apply to members or
employees of nonprofit
volunteer or governmental ambulance, rescue or emergency units, whether or not a user or
service fee may be
charged by the nonprofit unit or the governmental entity and whether or not the members
or employees receive
salaries or other compensation from the nonprofit unit or the governmental entity. This
section shall not be
construed to require a person who is ill or injured to be administered first aid or emergency
treatment if such
person objects thereto on religious grounds. This section shall not apply if such first aid or
emergency treatment
or assistance is rendered on the premises of a hospital or clinic.
§ 6802. Exempting nurses from civil liability in rendering emergency care
Any registered nurse or any licensed practical nurse, licensed as such by any state, who in
good faith renders emergency
care at the scene of any emergency or who undertakes to transport any victim thereof to the
nearest medical facility shall
not be liable for any civil damages as a result of any act or omission in rendering the
emergency care; provided,

58

however, such act or omission is not grossly negligent or intentionally designed to harm the
victim.

24 DELAWARE CODE
CHAPTER 19. NURSING
“NURSE PRACTICE ACT”
SECTION.
1

1901. Declaration of legislative intent.
1902. Definitions.
1903. Delaware Board of Nursing – Appointments; qualifications; terms of office; vacancies;
suspension or
removal.
1904. Delaware Board of Nursing – Election of officers; quorum; rules and regulations;
special meetings;
compensation; seal.
1905. Delaware Board of Nursing – Executive Director.
1906. Delaware Board of Nursing – Powers and duties.
1907. Delaware Board of Nursing – Revenue and expenses.
1908. Delaware Board of Nursing – Meetings; examinations for licensing; nursing education
programs; fees.
1909. License requirement.
1910. Qualifications for registered nurse.
1911. Licensure by examination for registered nurse.
1912. Reciprocity for registered nurse.
1913. Registered nurses licensed under previous law.
1914. Qualifications for licensed practical nurse.
1915. Licensure by examination for licensed practical nurse.
1916. Reciprocity for licensed practical nurse.
1917. Licensed practical nurses licensed under previous law.
1918. Renewal of license; lapse of license; penalties; retirement from practice; temporary
permit to practice.
1919. Nursing educational programs.
1920. License requirements; use of abbreviations.
1921. Applicability of chapter.
1922. Disciplinary proceedings; appeal.
1923. Temporary suspension: pending hearing.
1924. Unlawful practices.
1925. Penalties.
1926. Status of present Board members.
1927. Prescription requirements.
1 Refer to Delaware Code for sections not included.

Section A - 45 - 7-2007
Chapter 19A – INTERSTATE NURSE LICENSURE COMPACT1
1901A. Interstate Nurse Licensure Compact
1902A. Disciplinary action in Delaware
1903A. Effect of other obligations
1904A. Compact as controlling law
1905A. Continuation of Compact
§ 1901. Declaration of legislative intent
The General Assembly hereby declares the practice of nursing by competent persons is
necessary for the protection of
the public health, safety and welfare and further finds that the levels of practice within the
profession of nursing should

59

be regulated and controlled in the public interest. In order to safeguard life and health, the
general administration and
supervision of the education, examination, licensing and regulation of professional and
practical nursing is declared
essential, and such general administration and supervision is vested in the Board of Nursing.
§ 1902. Definitions
(a) “Administration of medications” means a process whereby a single dose of a prescribed
drug or biological is
given to a patient by an authorized licensed person by 1 of several routes, oral, inhalation,
topical, or parenteral.
The person verifies the properly prescribed drug order, removes the individual dose from a
previously dispensed,
properly labeled container (including a unit dose container), assesses the patient’s status to
assure that the drug is
given as prescribed to the patient for whom it is prescribed and that there are no known
contraindications to the
use of the drug or the dosage that has been prescribed, gives the individual dose to the
proper patient, records the
time and dose given and assesses the patient following the administration of medication for
possible untoward
side effects.
(b) (1) “Advanced practice nurse” means an individual whose education and certification
meet criteria
established by the Board of Nursing who is currently licensed as a registered nurse and has
a master’s
degree or a postbasic program certificate in a clinical nursing specialty with national
certification. When
no national certification at the advanced level exists, a master’s degree in a clinical nursing
specialty will
qualify an individual for advanced practice nurse licensure. “Advanced practice nurse” shall
include, but
not be limited to, nurse practitioners, certified registered nurse anesthetists, certified nurse
midwives or
clinical nurse specialists. Advanced practice nursing is the application of nursing principles,
including
those described in subsection (b) of this section, at an advanced level and includes:
a. For those advanced practice nurses who do not perform independent acts of diagnosis or
prescription, the authority as granted within the scope of practice rules and regulations
promulgated
by the Board of Nursing; and
b. For those advanced practice nurses performing independent acts of diagnosis and/or
prescription
with the collaboration of a licensed physician, dentist, podiatrist or licensed Delaware health
care
delivery system without written guidelines or protocols and within the scope of practice as
defined in
the rules and regulations promulgated by the Joint Practice Committee and approved by the
Board of
Medical Practice.
Nothing in this act is to be construed to limit the practice of nursing by advanced practice
nurses as is
currently being done or allowed including nursing diagnosis as pursuant to subsection (b)(2)
of this section.
Advanced practice nurses shall operate in collaboration with a licensed physician, dentist,
podiatrist, or

60

licensed Delaware health care delivery system to cooperate, coordinate, and consult with
each other as
appropriate pursuant to a collaborative agreement defined in the rules and regulations
promulgated by the
Board of Nursing, in the provision of health care to their patients. Advanced practice nurses
desiring to
practice independently or to prescribe independently must do so pursuant to § 1906(20) of
Title 24.
(2) Those individuals who wish to engage in independent practice without written guidelines
or protocols
and/or wish to have independent prescriptive authority shall apply for such privilege or
privileges to the
Joint Practice Committee and do so only in collaboration with a licensed physician, dentist,
podiatrist or
1 Refer to Delaware Code for complete text.

Section A - 46 - 7-2007
licensed Delaware health care delivery system. This does not include those individuals who
have protocols
and/or waivers approved by the Board of Medical Practice.
(c) “Assistance with medications” means a situation where a designated care provider
functioning in a setting
authorized by § 1921 of this title, who has taken a Board approved medication training
program, or a designated
care provider who is otherwise exempt from the requirement of having to take the Board
approved self
administration with medication training programs, assists the patient in the selfadministration of a medication
other than by injection, provided that the medication is in the original container, with a
proper label and
directions. The designated care provider may hold the container for the patient, assist with
the opening of the
container and assist the patient in taking the medication.
(d) The “Compact Administrator” shall be the Executive Director of the Delaware Board of
Nursing who shall be
designated as the Compact Administrator by the President of the Board.
(e) “Dispensing” means providing medication according to an order of a practitioner duly
licensed to prescribe
medication. The term shall include both the repackaging and labeling of medications form
bulk to individual
dosages.
(f) The “Head of the Nursing Licensing Board” shall be the President of the Delaware Board
of Nursing; and
(g) “Independent practice by an advanced practice nurse” shall include those advance
practice nurses who
practice and prescribe without written guidelines or protocols but with a collaborative
agreement with a licensed
physician, dentist, podiatrist or licensed Delaware health care delivery system and with the
approval of the Joint
Practice Committee.
(h) “Licensure” means the authorization to practice nursing within this State granted by the
Delaware Board of
Nursing and includes the authorization to practice in Delaware under the Interstate Nurse
Licensure Compact.
(i) “Nursing diagnosis” means the description of the individual’s actual or potential health
needs which are

61

identified through a nursing assessment and are amenable to nursing intervention. The
focus of the nursing
diagnosis is on the individual’s response to illness or other factors that may adversely affect
the attainment/or
maintenance of wellness. These diagnostic acts are distinct from medical, osteopathic and
dental diagnosis.
(j) “Nursing education program” means a course of instruction offered and conducted to
prepare persons for
licensure as a registered or licensed practical nurse, and/or a course of instruction offered
and conducted to
increase the knowledge and skills of the nurse and leads to an academic degree in nursing,
and/or refresher
courses in nursing.
(k) “Standards of nursing practice” means those standards of practice adopted by the Board
that interpret the legal
definitions of nursing, as well as provide criteria against which violations of the law can be
determined. Such
standards of nursing practice shall not be used to directly or indirectly affect the
employment practices and
deployment of personnel by duly licensed or accredited hospitals and other duly licensed or
accredited health care
facilities and organizations. In addition, such standards shall not be assumed the only
evidence in civil
malpractice litigation, nor shall they be given a different weight than any other evidence.
(l) “Substantially related” means the nature of the criminal conduct, for which the person
was convicted, has a
direct bearing on the fitness or ability to perform 1 or more of the duties or responsibilities
necessarily related to
the practice of nursing.
(m) “The practice of practical nursing” as a licensed practical nurse means the performance
for compensation of
nursing services by a person who holds a valid license pursuant to the terms of this chapter
and who bears
accountability for nursing practices which require basic knowledge of physical, social and
nursing sciences.
These services, at the direction of a registered nurse or a person licensed to practice
medicine, surgery or dentistry,
include:
(1) Observation;
(2) Assessment;
(3) Planning and giving of nursing care to the ill, injured and infirm;
(4) The maintenance of health and well being;
(5) The administration of medications and treatments prescribed by a licensed physician,
dentist, podiatrist or
advanced practice nurse; and
(6) Additional nursing services and supervision commensurate with the licensed practical
nurse’s continuing
education and demonstrated competencies; and
(7) Dispensing activities only as permitted in the board’s Rules and Regulations.
Nothing contained in this chapter shall be deemed to permit acts of surgery or medical
diagnosis; nor shall it be
deemed to permit dispensing of drugs, medications or therapeutics independent of the
supervision of a physician
who is licensed to practice medicine and surgery, or those licensed to practice dentistry or
podiatry.

62

Section A - 47 - 7-2007

(n) “The practice of professional nursing” as a registered nurse means the performance of
professional nursing
services by a person who holds a valid license pursuant to the terms of this chapter, and
who bears primary
responsibility and accountability for nursing practices based on specialized knowledge,
judgment and skill derived
from the principles of biological, physical and behavioral sciences. The registered nurse
practices in the
profession of nursing by the performance of activities, among which are:
(1) Assessing human responses to actual or potential health conditions;
(2) Identifying the needs of the individual and/or family by developing a nursing diagnosis;
(3) Implementing nursing interventions based on the nursing diagnosis;
(4) Teaching health care practices. Nothing contained herein shall limit other qualified
persons or agencies
from teaching health care practices without being licensed under this chapter;
(5) Advocating the provision of health care services through collaboration with other health
service personnel;
(6) Executing regimens, as prescribed by a licensed physician, dentist, podiatrist or
advanced practice nurse,
including the dispensing and/or administration of medications and treatments;
(7) Administering, supervising, delegating and evaluating nursing activities.
(8) Nothing contained in this chapter shall be deemed to permit acts of surgery or medical
diagnosis; nor shall
it be deemed to permit dispensing of drugs, medications or therapeutics independent of the
supervision of a
physician who is licensed to practice medicine and surgery, or those licensed to practice
dentistry or
podiatry.
A registered nurse shall the authority, as part of professional nursing, to make a
pronouncement of death;
provided, however, that this provision shall only apply to attending nurses caring for
terminally ill patients or
patients who have “do not resuscitate” orders in the home or place of residence of the
deceased as a part of a
hospice program or a certified home health care agency program; in a skilled nursing
facility; in a residential
community associated with a skilled nursing facility; any licensed assisted living community;
in an extended care
facility; or in a hospice; and provided that the attending physician of record has agreed in
writing to permit the
attending registered nurse to make a pronouncement of death in that case.
(o) “The profession of nursing” is an art and process based on a scientific body of
knowledge. The practitioner of
nursing assists patients in the maintenance of health, the management of illness, injury or
infirmity or in the
achieving of a dignified death.
§ 1905. Delaware Board of Nursing – Executive Director
The Executive Director shall be a registered nurse with at least 5 years experience in an
administrative or teaching
position, have earned a master’s degree in nursing, nursing education, education or a
related health field.
§ 1906. Delaware Board of Nursing – Powers and duties
(a) The Board shall:

63

(1) Adopt and, from time to time, revise such rules and regulations and standards not
inconsistent with the law
as may be necessary to enable it to carry into effect this chapter;
(2) Approve curricula and develop criteria and standards for evaluating educational
programs preparing
persons for license under this chapter;
(3) Provide for surveys of such programs at such times as it may deem necessary;
(4) Approve such programs as meet the requirements of this chapter and of the Board;
(5) Deny or withdraw approval from educational programs for failure to meet approved
curricula or other
criteria;
(6) Examine, license and renew licenses of duly qualified applicants, including applicants for
conducting
nursing educational programs and shall also prescribe the procedures for subsequent
examinations of
applicants who fail an examination;
(7) Establish categories of advanced practice nurses which shall include, but not be limited
to, pediatric nurse
practitioner, family nurse practitioner, maternal-gynecological nurse practitioner, clinical
specialist in
psychiatric-mental health nursing, nurse anesthetist and gerontological nurse practitioner
and standards for
the advanced practice nurse in each category. Such standards shall take into account the
type of advanced
levels of nursing practice which are or may be performed and the clinical and didactic
education,
experience or both needed to practice safely at those levels. In setting such standards, the
Board shall
consult with advanced practice nurses and physicians and health care organizations utilizing
advanced

Section A - 48 - 7-2007
practice nurses. The standards shall be consistent with the national certifying organization
standards of
practice recognized by the Board in its rules and regulations;
(8) Issue a temporary permit to practice nursing to applicants who apply for licensure by
endorsement and to
new graduates awaiting results of the first licensing examination;
(9) Conduct hearings upon charges calling for discipline of a licensee or revocation of a
license;
(10) Have the power to issue subpoenas and compel the attendance of witnesses, and
administer oaths to persons
giving testimony at hearings;
(11) Cause the prosecution of all persons violating this chapter and have the power to incur
such necessary
expenses therefor;
(12) Keep a record of all its proceedings;
(13) Make an annual report to the Governor;
(14) Have all of the duties, powers and authority necessary to the enforcement of this
chapter, as well as such
other duties, powers and authority as it may be granted from time to time by appropriate
statute;
(15) Appoint advisory committees as the Board deems desirable;
(16) Maintain a system of statistics related to nursing education programs and registered
nurse and licensed
practical nurse licensure in the State;

64

(17) Participate in and pay fees to the national organization of state boards of nursing, the
National Council of
State Boards of Nursing, Inc.;
(18) By regulation, establish requirements for mandatory continuing education;
(19) Create a regulatory committee entitled “Joint Practice Committee” to develop rules and
regulations
regarding the independent practice and prescriptive authority of “advance practice nurses.”
The Committee
shall consist of 9 members and shall be as follows:
a. The Board of Nursing shall appoint 1 public member and 5 advanced practice nurses.
b. The Board of Pharmacy shall appoint 1 pharmacist.
c. The Board of Medical Practice shall appoint 2 physicians.
(20) The “Joint Practice Committee” with the approval of the Board of Medical Practice shall
have the authority
to grant, restrict, suspend or revoke practice or independent prescriptive authority and the
Joint Practice
Committee with the approval of the Board of Medical Practice shall be responsible for
promulgating rules
and regulations to implement the provisions of this chapter regarding “advanced practice
nurses” who have
been granted authority for independent practice and/or independent prescriptive authority.
(21) The rules and regulations and the granting, restricting, suspension or revocation of the
independent practice
and/or independent prescriptive authority shall be subject to the approval of the Board of
Medical Practice.
(b) The Board of Nursing shall promulgate regulations specifically identifying those crimes
which are substantially
related to the practice of nursing.
§ 1909. License requirement
No unlicensed person, except those persons issued a temporary permit by the Board, shall
practice advanced practice,
professional or practical nursing. Upon request, any person engaged in the practice of
advanced practice, professional or
practical nursing shall exhibit a license authorizing such practice.
§ 1910. Qualifications for registered nurse
An applicant for a license to practice as a registered nurse shall submit to the Board written
evidence, verified by oath,
that the applicant:
(1) Is a graduate of and holds a certificate from a State Board of Nursing approved nursing
education program that is
authorized to prepare persons for licensure as a registered nurse;
(2) Demonstrates competence in English related to nursing;
(3) Must show evidence of an earned high school diploma or its equivalent;
(4) Is of such satisfactory physical and mental health as is consistent with the Americans
with Disabilities Act; [42
U.S.C. § 12101 et. seq.];
(5) Has committed no acts which are grounds for disciplinary action as set forth in 1922(a) of
this title; however, after
a hearing, the Board, by an affirmative vote of a majority of the quorum may waive §
1922(a)(2) of this title,
herein, if it finds all of the following:
a. More than 5 years have elapsed since the applicant has fully discharged all imposed
sentences. As used
herein, the term "sentence" includes, but is not limited to, all periods of modification of a
sentence,

65

Section A - 49 - 7-2007

probation, parole or suspension. However, sentence does not include fines, restitution or
community
service, as long as the applicant is in substantial compliance with such fines, restitution and
community
service.
b. The applicant is capable of practicing nursing in a competent and professional manner.
c. The granting of a waiver will not endanger the public health, safety or welfare; and
(6) If seeking licensure by endorsement, demonstrates active employment in professional
nursing in the past 5 years,
or satisfactory completion of a professional nursing refresher program with an approved
agency within 2 years
prior to filing an application. In the event no refresher course is available the Board may
consider alternate
methods of evaluating current knowledge in professional nursing.
§ 1914. Qualifications for licensed practical nurse
An applicant for a license to practice as a licensed practical nurse shall submit to the Board
written evidence, verified by
oath, that such applicant:
(1) Is a graduate of and holds a certificate from a State Board of Nursing approved practical
nursing education
program;
(2) Demonstrates competence in English related to nursing;
(3) Must show evidence of an earned high school diploma or its equivalent;
(4) Is of such satisfactory physical and mental health as is consistent with the Americans
with Disabilities Act;
(5) Has committed no acts which are grounds for disciplinary action as set forth in 1922(a) of
this title; however, after
a hearing, the Board, by an affirmative vote of a majority of the quorum may waive §
1922(a)(2) of this title,
herein, if it finds all of the following:
a. More than 5 years have elapsed since the applicant has fully discharged all imposed
sentences. As used
herein, the term "sentence" includes, but is not limited to, all periods of modification of a
sentence,
probation, parole or suspension. However, sentence does not include fines, restitution or
community
service, as long as the applicant is in substantial compliance with such fines, restitution and
community
service.
b. The applicant is capable of practicing nursing in a competent and professional manner.
c. The granting of a waiver will not endanger the public health, safety or welfare; and
(6) If seeking licensure by endorsement, demonstrates active employment in practical
nursing in the past 5 years, or
satisfactory completion of a practical nursing refresher program with an approved agency
within 2 years prior to
filing an application. In the event no refresher course is available the Board may consider
alternate methods of
evaluating current knowledge in practical nursing.
§ 1918. Renewal of license; lapse of license; penalties; retirement from practice; temporary
permit to practice
(a) Every advanced practice nurse, registered or licensed practical nurse licensed under this
chapter shall reregister
biennially by filing an application; provided, however, that the license of any licensee who is
on active military

66

duty with the Armed Forces of the United States and serving in a theater of hostilities on the
date such application
or reregistration is due shall be deemed to be current and in full compliance with this
chapter until the expiration
of 60 days after such licensee is no longer on active military duty in a theater of hostilities.
The advanced practice
nurses’ independent practice and/or independent prescriptive authority shall be subject to
biennial renewal upon
application made to the “Joint Practice Committee.” In the event the applicant has not been
actively employed in
professional practical nursing in the past 5 years, the applicant will be required to give
evidence of satisfactory
completion of a professional or practical nursing refresher program within an approved
agency within 2 years
prior to renewal before licensure by renewal will be granted.
(b) Upon receipt of the application and fee, the Board shall verify the accuracy of the
information set forth in the
application and issue to the applicant a certificate of renewal of license for 2 years, provided
that the applicant has
successfully completed continuing education requirements as may be established by the
Board. Such certificate
shall entitle the holder to engage in the practice of professional or practical nursing for the
period stated therein.
Any licensee whose license lapses for failure to renew the license may be reinstated by the
Board upon
satisfactory evidence of active employment in professional or practical nursing within the
past 5 years or
satisfactory completion of a refresher program in professional or practical nursing within an
approved agency
within a 1-year period prior to renewal and upon satisfactory explanation for the failure to
renew the license and
payment of a penalty fee to be determined.

Section A - 50 - 7-2007
(c) After a license has lapsed or been inactive for 5 or more years and the applicant has not
been in active practice in
professional or practical nursing in the past 5 years, the applicant will be required to give
evidence of satisfactory
completion of a professional or practical nursing refresher program within an approved
agency within 2 years
prior to reinstatement before licensure by reinstatement will be granted. In the event no
refresher course is
available the Board may consider alternate methods of evaluating current knowledge in
professional or practical
nursing.
(d) Any person practicing nursing during the time his or her license has lapsed shall be
considered an illegal
practitioner and shall be subject to the penalties provided for violations of this chapter.
(e) Any person licensed under this chapter who desires to retire from practice in this State
shall so notify the Board.
Upon receipt of such notice, the Board shall place the name of such person on a
nonpracticing list. While on this
list, such person shall not be required to pay any license fee, and shall not practice nursing
in this State. When
such person desires to resume practice, application for renewal shall be made under
subsection (a) of this section

67

and the license shall be reactivated if the requirements of the Board are met.
(f) Temporary permits to practice nursing may be issued by the Board to persons who have
requested reinstatement
of their license, if they have practiced nursing within the past 5 years.
(g) Every registered or licensed practical nurse licensed under this chapter primarily
engaged in the practice of
electrolysis shall be exempt from the requirement in subsection (a) of this section that states
in the event the
applicant has not been actively employed in professional practical nursing in the past 5
years, the applicant will be
required to give evidence of satisfactory completion of a professional or practical nursing
refresher program
within 2 years prior to renewal before licensure by renewal will be granted.
§ 1920. License requirements; use of abbreviations
(a) No person shall engage in the practice of professional nursing in Delaware without being
licensed by the Board,
except those persons issued a temporary permit by the Board.
(b) No person shall engage in practice as an advanced practice nurse without a Board-issued
license as an advanced
practice nurse.
(c) No person shall knowingly employ a graduate of a professional nursing program or a
registered nurse to engage in
the practice of professional nursing without a temporary permit or license from the Board.
(d) Only registered nurses shall use that title, the abbreviation of “R.N.” or any other words,
letters, signs or figures
indicating that the person using the same is a registered nurse.
(e) No person shall practice practical nursing in Delaware without being licensed by the
Board, except those persons
issued a temporary permit by the Board.
(f) No person shall knowingly employ a graduate of a practical nursing program or a licensed
practical nurse to
engage in the practice of practical nursing without a temporary permit or license from the
Board.
(g) Only licensed practical nurses shall use that title, the abbreviation “L.P.N.” or any other
words, letters, signs or
figures indicating that the person using the same is a licensed practical nurse.
§ 1921. Applicability of chapter
(a) This chapter shall not apply to the following situations:
(1) Nursing services rendered during an epidemic or a state or national disaster;
(2) The rendering of assistance by anyone in the case of an emergency;
(3) Emergency services rendered by ambulance personnel trained in advanced life support
under a licensed
physician’s supervision as defined in Chapter 79 of Title 29. Advanced life support is defined
in Chapter
79 of Title 29;
(4) The incidental care of the sick in private homes by members of the family, friends,
domestic servants or
persons primarily employed as housekeepers;
(5) Nursing services rendered by a student enrolled in a State Board of Nursing approved
school of
professional or practical nursing when these services are incidental to the course of study; or
those nursing
services rendered by a professional nurse or practical nurse enrolled in a State Board of
Nursing approved
refresher course pending reinstatement, reactivation or endorsement of licensure;

68

(6) The practice of nursing in this State by a nurse licensed in another state whose
employment requires such
nurse to accompany and care for a patient temporarily in this State, provided the nursing
services are not
rendered for more than 3 months within 1 year and such nurse does not claim to be licensed
in this State;

Section A - 51 - 7-2007
(7) The practice of nursing by a nurse licensed in another state employed by the United
States government or
any bureau, division or agency thereof;
(8) The practice of nonmedical nursing in connection with healing by prayer or spiritual
means in accordance
with the tenets and practice of a well-recognized church or religious denomination, provided
that persons
practicing such nonmedical nursing do not claim to be licensed under this chapter;
(9) Auxiliary care services performed by nurse’s aides, attendants, orderlies and other
auxiliary workers in
medical care facilities, or elsewhere by persons under the direction and supervision of a
person licensed to
practice nursing, medicine, dentistry or podiatry, and performing those services which are
routine,
repetitive and limited in scope, and that do not require the professional judgment of a
registered nurse or a
licensed practical nurse; provided, however, that nothing contained herein shall limit the
right of any person
to act pursuant to paragraph (7) of subsection (e) of § 1703 of this title, or persons employed
in similar
positions in the offices of podiatrists or dentists without being licensed under this chapter;
(10) Residential child care facilities regulated by the State under Title 31 where designated
child care providers,
who have successfully completed a Board-approved medication training program, assist
children in the
taking of medication, other than by injection, provided that the medication is in the original
container,
properly labeled. An annual report by the Administrator of the Program shall be made to the
Board of
Nursing. The report shall indicate compliance with guidelines as set forth in the approved
course on
“Assistance with Self Administration;”
(11) Administration of prescription or nonprescription medications, other than by injection,
by child care
providers who have successfully completed a state-approved medication training program,
to children in
child day care homes or child day care centers regulated by the State under §§ 341-344 of
Title 31;
provided the medication and written permission for the administration of the particular
medication has been
obtained from the child’s parent or legal guardian and further provided the medication is in
its original
container, properly labeled. Properly labeled medication shall include instructions for
administration of the
medication;
(12) Foster homes, group homes or adult day habilitation centers for individuals who are
developmentally

69

disabled regulated by the State under Chapter 55 of Title 16 where designated care
providers, who have
successfully completed a Board-approved medication training program, assist
developmentally disabled
clients in the taking of medication, other than by injection, provided that the medication is in
the original
container, properly labeled. An annual report by the Administrator of the Program shall be
made to the
Board of Nursing. The report shall indicate compliance with guidelines as set forth in the
approved course
on “Assistance with Self Administration;”
(13) Nursing services rendered by a graduate of a State Board of Nursing approved school of
professional or
practical nursing working under supervision, pending results of the first licensing
examination. The Board
shall establish the procedure and extent to which subsequent examinations may be taken
and the length of
time and the character of nursing service which may be rendered pending subsequent
examinations;
(14) Group homes for individuals who have psychiatric disabilities regulated by the State
under Chapter 11 of
Title 16 and other community support programs certified by the Division of Substance Abuse
and Mental
Health, where designated care providers, who have successfully completed a Boardapproved medication
training program, assist individuals who have psychiatric disabilities in the taking of
medication, other than
by injection, provided that the medication is in the original container, properly labeled. An
annual report
by the Administrator of the Program shall be made to the Board of Nursing. The report shall
indicate
compliance with guidelines as set forth in the approved course on “Assistance with Self
Administration;”
(15) The practice of any currently licensed registered nurse or licensed practical nurse of
another state who
provides or attends educational programs or provides consultative services within this State
not to exceed
14 days in any calendar year. Neither the education nor consultation may include the
provision of patient
care, the direction of patient care or the affecting of patient care policies;
(16) Assisted Living agencies serving elderly persons and adults with physical disabilities
regulated by the State
under Chapter 11 of Title 16, where designated care providers, who have successfully
completed a Boardapproved
medication training program, assist individuals residing in licensed assisted living facilities in
the
taking of medication, other than by injection, provided that the medication is in the original
container, and
properly labeled. An annual report by the Administrator of the Program shall be made to the
Board of
Nursing. The report shall indicate compliance with guidelines as set forth in the approved
course on
“Assistance with Self Administration;”

Section A - 52 - 7-2007
70

(17) Educators who assist students with medications that are self-administered during school
field trips that have
completed a Board of Nursing approved training course developed by the Delaware
Department of
Education;
(18) Attendants providing basic and ancillary services defined and regulated by the
Department of Health and
Social Services in conformity with the Community-Based Attendant Services Act, Chapter 94
of Title 16.
(19) A competent individual who does not reside in a medical facility or a facility regulated
pursuant to Chapter
11 of Title 16, may delegate to unlicensed persons performance of health care acts, unless
of a nature
excluded by the Board through regulations, provided:
a. The acts are those individuals could normally perform themselves but for functional
limitations; and
b. The delegation decision is entirely voluntary.
Nothing contained herein shall diminish any legal or contractual entitlement to receive
health care services from
licensed or certified personnel.
(b) Persons involved in the rendering of electrolysis treatments shall be eligible for licensing
under this chapter
regardless of whether the applicant is in compliance with subdivision (6) of § 1910 of this
title, or subdivision (6)
of § 1914 of this title, so long as such applicants are in compliance with subdivisions (1)
through (5) of either §
1910 or 1914 of this title.
§ 1922. Disciplinary proceedings; appeal
(a) Grounds. The Board may impose any of the following sanctions (subsection (b) of this
section) singly or in
combination when it finds a licensee or former licensee is guilty of any offense described
herein:
(1) Is guilty of fraud or deceit in procuring or attempting to procure a license to practice
nursing; or
(2) Is convicted of a crime that is substantially related to the practice of nursing; or
(3) Is unfit or incompetent by reason of negligence, habits or other causes; or
(4) Is habitually intemperate or is addicted to the use of habit-forming drugs; or
(5) Is mentally incompetent; or
(6) Whose physical condition is such that the performance of nursing service is or may be
injurious or
prejudicial to patients or to the public; or
(7) Has had a license to practice as a registered nurse or licensed practical nurse suspended
or revoked in any
jurisdiction; or
(8) Is guilty of unprofessional conduct as shall be determined by the Board, or the willful
neglect of a patient;
or
(9) Has willfully or negligently violated this chapter.
(b) Disciplinary sanctions.
(1) Permanently revoke a license to practice.
(2) Suspend a license.
(3) Censure a license.
(4) Issue a letter of reprimand.
(5) Place a licensee on probationary status and require the licensee to:
a. Report regularly to the Board upon the matters which are the basis of probation.

71

b. Limit practice to those areas prescribed by the Board.
c. Continue or renew professional education until satisfactory degree of skill has been
attained in those
areas which are the basis of the probation.
(6) Refuse a license.
(7) Refuse to renew a license.
(8) Or otherwise discipline.
(c) Procedure.
(1) When a complaint is filed pursuant to § 8810 of Title 29, alleging a violation of this
chapter, the complaint
shall be received and investigated by the Division of Professional Regulation and the Division
shall be
responsible for issuing a final written report at the conclusion of its investigation.
(2) The Board shall cause a copy of the complaint, together with a notice of the time and
place fixed for the
hearing, to be served upon the practitioner at least 30 days before the date fixed for the
hearing. In cases
where the practitioner cannot be located or where personal service cannot be effected,
substitute service
shall be effected in the same manner as with civil litigation.
(3) In all proceedings herein:

Section A - 53 - 7-2007
a. The accused may be represented by counsel who shall have the right of examination and
crossexamination.
b. The accused and the Board may subpoena witnesses. Subpoenas shall be issued by the
President or
the Vice-President of the Board upon written request and shall be served as provided by the
rules of
Superior Court and shall have like effect as a subpoena issued by said Court.
c. Testimony before the Board shall be under oath. Any member of the Board shall have
power to
administer oaths for this purpose.
d. A stenographic record of the hearing shall be made by a qualified court reporter. At the
request and
expense of any party such record shall be transcribed with a copy to the other party.
e. The decision of the Board shall be based upon sufficient legal evidence. If the charges are
supported
by such evidence, the Board may refuse to issue, or revoke or suspend a license, or
otherwise
discipline a licensee. A suspended license may be reissued upon a further hearing initiated
at the
request of the suspended licensee by written application in accordance with the rules of the
Board.
f. All decisions of the Board shall be final and conclusive. Where the practitioner is in
disagreement
with the action of the Board, he or she may appeal the Board’s decision to the Superior
Court within
30 days of service or of the postmarked date of the copy of the decision mailed to him or
her. The
appeal shall be on the record to the Superior Court and shall be as provided in §§ 1014210145 of
Title 29.
§ 1924. Unlawful practices
(a) No person shall practice or offer to practice professional or practical nursing or shall
represent himself or herself

72

as a registered nurse or licensed practical nurse in this State, or shall use any title,
abbreviation, sign, card or
device to indicate that such person is a registered nurse or licensed practical nurse, unless
such person is licensed
under this chapter.
(b) No person, hospital or institution shall conduct or shall offer to conduct a professional or
practical nursing
education program unless such person, hospital or institution is approved under this chapter.

CHAPTER 19A. INTERSTATE NURSE LICENSURE COMPACT1
§ 1901A. The Interstate Nurse Licensure Compact.
The State hereby enters into the Interstate Nurse Licensure Compact as set forth in this
chapter. The text of the Compact
is as follows:
Interstate Nurse Licensure Compact
Article I – Findings and Declaration of Purpose
(a) The party states find that:
(1) The health and safety of the public are affected by the degree of compliance with and
the effectiveness of
enforcement activities related to state nurse licensure laws;
(2) Violations of nurse licensure and other laws regulating the practice of nursing may result
in injury or harm
to the public;
(3) The expanded mobility of nurses and the use of advanced communication technologies
as part of our
nation’s healthcare delivery system require greater coordination and cooperation among
states in the areas
of nurse licensure and regulation;
(4) New practice modalities and technology make compliance with individual state nurse
licensure laws
difficult and complex; and
(5) The current system of duplicative licensure for nurses practicing in multiple states is
cumbersome and
redundant to both nurses and states.
(b) The general purposes of this Compact are to:
(1) Facilitate the states’ responsibility to protect the public’s health and safety;
(2) Ensure and encourage the cooperation of party states in the areas of nurse licensure and
regulation;
1 Refer to Delaware Code for complete text.

Section A - 54 - 7-2007
(3) Facilitate the exchange of information between party states in the areas of nurse
regulation, investigation,
and adverse actions;
(4) Promote compliance with the laws governing the practice of nursing in each jurisdiction;
and
(5) Invest all party states with the authority to hold a nurse accountable for meeting all state
practice laws in
the state in which the patient is located at the time care is rendered through the mutual
recognition of party
state licenses.
Article II – Definitions
As used in this Compact:
(a) “Adverse Action” means a home or remote state action.
(b) “Alternative program” means a voluntary, non-disciplinary monitoring program approved
by a nurse licensing
board.

73

(c) “Coordinated licensure information system” means an integrated process for collecting,
storing, and sharing
information on nurse licensure and enforcement activities related to nurse licensure laws,
which is administered
by a non-profit organization composed of and controlled by state nurse licensing boards.
(d) “Current significant investigative information” means:
(1) Investigative information that a licensing board, after a preliminary inquiry that includes
notification and an
opportunity for the nurse to respond if required by state law, has reason to believe is not
groundless and, if
proved true, would indicate more than a minor infraction; or
(2) Investigative information that indicates that the nurse represents an immediate threat to
public health and
safety regardless of whether the nurse has been notified and had an opportunity to respond.
(e) “Home state” means the party state which is the nurse’s primary state of residence.
(f) “Home state action” means any administrative, civil, equitable or criminal action
permitted by the home state’s
laws which are imposed on a nurse by the home state’s licensing board or other authority
including actions
against an individual’s license such as: revocation, suspension, probation or any other action
which affects the
nurse’s authorization to practice.
(g) “Licensing board” means a party state’s regulatory body responsible for issuing nurse
licenses.
(h) “Multistate licensure privilege” means current, official authority from a remote state
permitting the practice of
nursing as either a registered nurse or a licensed practical/vocational nurse in such party
state. All party states
have the authority, in accordance with existing state due process law, to take actions
against the nurse’s privilege
such as: revocation, suspension, probation or any other action which affects a nurse’s
authorization to practice.
(i) “Nurse” means a registered nurse or licensed practical/vocational nurse, as those terms
are defined by each
party’s state practice laws.
(j) “Party state” means any state that has adopted this Compact.
(k) “Remote state” means a party state, other than the home state,
(1) Where the patient is located at the time nursing care is provided, or,
(2) In the case of the practice of nursing not involving a patient, in such party state where
the recipient of
nursing practice is located.
(l) “Remote state action” means
(1) Any administrative, civil, equitable or criminal action permitted by a remote state’s laws
which are
imposed on a nurse by the remote state’s licensing board or other authority including
actions against an
individual’s multistate licensure privilege to practice in the remote state, and
(2) Cease and desist and other injunctive or equitable orders issued by remote states or the
licensing boards
thereof.
(m) “State” means a state, territory or possession of the United States, the District of
Columbia or the Commonwealth
of Puerto Rico.
(n) “State practice laws” means those individual party state’s laws and regulations that
govern the practice of

74

nursing, define the scope of nursing practice, and create the methods and grounds for
imposing discipline. “State
practice laws” does not include the initial qualifications for licensure or requirements
necessary to obtain and
retain a license, except for qualifications or requirements of the home state.
Article III - General Provisions and Jurisdiction:
(a) A license to practice registered nursing issued by a home state to a resident in that state
will be recognized by each
party state as authorizing a multistate licensure privilege to practice as a registered nurse in
such party state. A
license to practice licensed practical/vocational nursing issued by a home state to a resident
in that state will be
recognized by each party state as authorizing a multistate licensure privilege to practice as
a licensed

Section A - 55 - 7-2007
practical/vocational nurse in such party state. In order to obtain or retain a license, an
applicant must meet the
home state’s qualifications for licensure and license renewal as well as all other applicable
state laws.
(b) Party states may, in accordance with state due process laws, limit or revoke the
multistate licensure privilege of
any nurse to practice in their state and may take any other actions under their applicable
state laws necessary to
protect the health and safety of their citizens. If a party state takes such action, it shall
promptly notify the
administrator of the coordinated licensure information system. The administrator of the
coordinated licensure
information system shall promptly notify the home state of any such actions by remote
states.
(c) Every nurse practicing in a party state must comply with the state practice laws of the
state in which the patient is
located at the time care is rendered. In addition, the practice of nursing is not limited to
patient care, but shall
include all nursing practice as defined by the state practice laws of a party state. The
practice of nursing will
subject a nurse to the jurisdiction of the nurse licensing board and the courts, as well as the
laws, in that party
state.
(d) This Compact does not affect additional requirements imposed by states for advanced
practice registered nursing.
However, a multistate licensure privilege to practice registered nursing granted by a party
state shall be recognized
by other party states as a license to practice registered nursing if one is required by state
law as a precondition for
qualifying for advanced practice registered nurse authorization.
(e) Individuals not residing in a party state shall continue to be able to apply for nurse
licensure as provided for under
the laws of each party state. However, the license granted to these individuals will not be
recognized as granting
the privilege to practice nursing in any other party state unless explicitly agreed to by that
party state.
Article IV – Applications for Licensure in a Party State
(a) Upon application for a license, the licensing board in a party state shall ascertain,
through the coordinated

75

licensure information system, whether the applicant has ever held, or is the holder of, a
license issued by any other
state, whether there are any restrictions on the multistate licensure privilege, and whether
any other adverse action
by any state has been taken against the license.
(b) A nurse in a party state shall hold licensure in only 1 party state at a time issued by the
home state.
(c) A nurse who intends to change primary state of residence may apply for licensure in the
new home state in
advance of such change. However, new licenses will not be issued by a party state until after
a nurse provides
evidence of change in primary state of residence satisfactory to the new home state’s
licensing board.
(d) When a nurse changes primary state of residence by:
(1) Moving between 2 party states, and obtains a license from the new home state, the
license from the former
home state is no longer valid;
(2) Moving from a non-party state, and obtains a license from the new home state, the
individual state license
issued by the non-party state is not affected and will remain in full force if so provided by the
laws of the
non-party state;
(3) Moving from a party state to a non-party state, the license issued by the prior home
state converts to an
individual state license, valid only in the former home state, without the multistate licensure
privilege to
practice in other party states.
Article V – Adverse Actions
Article VI – Additional Authorities Invested in Party State Nurse Licensing Boards
Article VII – Coordinated Licensure Information System
Article VIII – Compact Administration and Interchange of Information
Article IX – Immunity
Article X – Entry into Force, Withdrawal, and Amendment
Article XI – Construction and Severability
§ 1902A. Disciplinary action in Delaware.
(a) All nurses holding a Delaware nursing license which is either under suspension or under
probation by the
Delaware Board of Nursing or who are participating in an established treatment program
which is an alternative to
disciplinary action, shall not practice in any other party state during the term of such
suspension, probation or
participation without prior authorization from such other party state. The Delaware nursing
licensure of any nurse
under such suspension, probation or participation who practices nursing in another party
state without prior
authorization from that state may be revoked by the Delaware Board of Nursing.

Section A - 56 - 7-2007
(b) The multi-state licensure privilege granted by this State is subject or revocation or other
disciplinary action as the
result of any disciplinary action imposed by a nurse’s home state.
§ 1903A. Effect of other obligations.
This Compact is intended to facilitate the regulation of the practice of nursing and does not
relieve employers from
complying with contractual and statutorily imposed obligations.
§ 1904A. Compact as controlling law.

76

If there is an irreconcilable conflict between the Interstate Nurse Licensure Compact and
Chapter 19 of Title 24, the
Compact shall control.
§ 1905A. Continuation of Compact.
This Compact and this State’s participation therein shall remain in full force and effect
beyond June 30, 2005, and shall
not terminate without further action of the General Assembly.

Section A - 57 - 7-2007
ATTORNEY GENERAL’S OPINION – JANUARY 20, 1994
Letter to Pascale D. Forgione, Superintendent
Delaware Department of Public Instruction

Re: Nurse in Attendance on Field Trips
You have asked whether disabled children must be permitted to participate in
school field trips and
whether a nurse must be in attendance under any circumstances. You have
also asked whether sick
children must be permitted to participate in field trips and whether a nurse
must be in attendance
under any circumstances. The right of a disabled child to receive necessary
medical services extends
to non-scholastic activities as well as academic activities. If the disabled child
requires a nurse to
administer medications during the academic day, that same assistance
should be afforded as an
accommodation to that child while on a field trip. As to the second question,
neither federal nor
Delaware law specifically outlines the rights of children in school who are
simply sick and generally
sick children should be allowed on trips except under certain circumstances
as discussed below.
As to disabled children, Section 504 of the Rehabilitation Act of 1973, as well
as the Americans
With Disabilities Act mandates that reasonable accommodations to the
physical or mental limitations
of any otherwise qualified disabled individual be made for that individual by
a public entity, unless
the entity can demonstrate the accommodation when imposed is an “undue
hardship on the operation
of its programs.” 45 C.F.R. §84.12 (a).
The case law amply demonstrates that disabled children are entitled to
receive necessary medical
services while in school. Irving Independence School District v. Tatro, 468
U.S. 883 (1984).
Further, other courts have held that schools must provide staff with the
training to administer
medical services and to assist the disabled child, if the need arises.
Department of Education v. D.,
77

531 F. Supp. 517 (D. Hawaii 1982); Department of Education, State of Hawaii
v. Catherine D., 727
F. 2d 809 (9th Cir. 1983). Moreover, the right of a disabled child to receive
necessary medical
services extends to non-scholastic activity as well. 34 C.F.R. §104-37 (a) (2).
If disabled children can participate in field trips when provided with the same
accommodations to
which they are entitled at school, this accommodation must be offered to
them. Quaker Valley (Pa)
School District Complaint No. 03861077 Education for the Handicapped Law
Report, 352:235
(Supp. 186 February 13, 1987). A reasonable accommodation includes
providing a nurse on school
trips and other school outings. 45 C.F.R. §84-12 (a).
As to the second question regarding sick children, federal and state law does
not deny access to
academic and school related activities for sick children but for when they
suffer from contagious
illnesses such as diphtheria, measles, scarlet fever or smallpox. This raises
the question as to
whether sick children can be assisted with medication while in school and on
filed trips by someone
other than a licensed nurse. It has been argued that the assistance of
medication is the practice of
nursing. We do not believe that necessarily to be so. Accordingly, a parent
should be permitted to
designate a care provider to assist her/his sick child. A parent can also
authorize a sick child to care
for themselves.
Section A - 58 - 7-2007
The mere assistance in taking medications is not the practice of nursing
under 24 Del. C. Ch. 19. 24
Del. C. §1902 (b) (6) states that a registered nurse execute regimens which
include the dispensing
and administration of medications. Twenty-four Del. C. §1902 (f) defines the
administration of
medication as an entire “process” whereby a nurse verifies the prescription
drug order; removes the
dose from a previously dispensed, properly labeled container; assesses the
patient’s status to assure it
is given as prescribed to the proper patient and that no known
contraindications to the drug or the
dosage exists; gives a dose to the patient; then records the time and dose
given. Further, under this
statute the nurse would check the patient following the administration of the
medication for possible
78

side effects. Id.
If the parent of a sick child consents to that child self-administering
medication or designates
someone to assist with medications, that child should be allowed to
participate in school field trips
and a nurse need not be provided as there is no mandate under either
federal or state law to
accommodate a sick child. However, a parent cannot designate a care giver
to act in such a way that
the care giver is administering medicine as described above. Parents can
consent to a care giver
assisting with medications.
‘Assistance with medications’ is defined in the nursing statute as follows:
(g) “Assistance with medications” means the designated care provider
assists the
patient in the self-administration of a drug, provided that the medication is in
the original container, with proper label and direction. The designated care
provider must hold the container for the patient, assist patient in taking the
medication.” 24 Del. C. §1902.
This statute does not include the assistance with medication as a practice to
be performed only by
nurses.
To conclude, if a child is disabled, the same accommodation afforded in an
academic setting must be
available on field trips as the child has a right under federal law to
participate in non-academic and
extracurricular activities. If that accommodation is a nurse, then the nurse
must be in attendance on
a field trip.
A nurse need not accompany sick children on field trips as parents can
consent to self-administration
of medication or appoint a designated care giver if necessary. However, the
designated care giver
must not take up the activities which would be considered administration of
medication under the
Nursing Act as described above.
Malcolm S. Cobin
Assistant State Solicitor
Loretta G. LeBar
Deputy Attorney General
Approved: Michael F. Foster
State Solicitor
Section A - 59 - 7-2007
ATTORNEY GENERAL’S OPINION – JULY 17, 1979
Re: Statement of Delaware Association
of Chiropractic Physicians and

79

Opinion of the Attorney General
No. 78-11

“In recent correspondence you have asked this office to determine whether
the position of the
Delaware Association of Chiropractic Physicians as stated in a letter from Dr.
John L. Stump dated
April 16, 1979, is legally consistent with an opinion rendered by this office on
January 30, 1978.
That opinion addressed the question of the legal acceptability of the
provision of certain chiropractic
services to public school pupils in Delaware.
The position of the chiropractic association as articulated in Dr. Stump’s April
16 letter to the State
School Health Advisory Committee states in relevant part as follows:
‘It is the responsibility of the prudent school officials to receive this
information
unbiasedly and apply it for the students benefit, as would be done from any
other
licensed Delaware physician or health care provider.’
The ‘information’ referred to in the paragraph above is a statement
concerning the present and future
state of the physical health of a public school pupil prepared by a
chiropractic physician. It is further
the position of the association that excuses for students so prepared are
temporary and second
opinions should be sought ‘if circumstances warrant.’ As discussed in our
prior opinion on this
subject, it is not the legal responsibility of school officials to receive excuses
so prepared. Delaware
Law does not authorize the recognition of such services by appropriate
school officials.
Opinion 78-11 outlined the regulations promulgated by the State Board of
Education which require
the services of physicians licensed to practice in Delaware for school health
services. The State
Board of Education has also adopted physician requirements for the
performance of physical
examinations of public school pupils before they enter the first grade, before
they participate in
organized sports, and before they may be medically excused from school
attendance.
Since the regulations described above are State regulations, individuals
performing such services
must be licensed to practice medicine pursuant to 24 Del. C. Ch. 17, the
Delaware Medical Practices

80

Act. Chiropractic physicians continue to be governed by the Delaware
Chiropractic law at 24 Del.
C. Ch. 7. This separation of statutory application has not been altered since
Opinion 78-11 was
issued in January, 1978. Therefore, a local Delaware school district may not
accept school or
physical education excuses signed by chiropractic physicians, nor may
districts accept
documentation of a school or athletic physical examination conducted by a
chiropractor. For these
reasons, the stated position of the Delaware Association of Chiropractic
Physicians is not consistent
with Delaware Law. As explained in an earlier letter dated January 19, 1979,
which clarified
Opinion 78-11, however, the determinations of chiropractic physicians should
not be simply
disregarded. The school district may wish to verify such determinations
through the opinions of
physicians licensed to practice under 24 Del. C. Ch. 17.”
Section A - 60 - 7-2007

III. STANDARDS
The complete text and description of the national Standards of Professional
School Nursing Practice are found in School Nursing: Scope and Standards of
Practice (2005). The document can be purchased through the National
Association of School Nurses (NASN) at P. O. Box 1300, Scarborough,
Maine 04070 or the NASN Bookstore.
Section A - 61 - 7-2007
STANDARDS OF PROFESSIONAL SCHOOL NURSING PRACTICE
National Association of School Nurses adopted November, 2004 1
Permission granted for republication.

STANDARDS OF PRACTICE
Standard 1. ASSESSMENT

The school nurse collects comprehensive data pertinent to the client’s health or the situation.

Standard 2. DIAGNOSIS

The school nurse analyzes the assessment data to determine the diagnosis or issues.

Standard 3. OUTCOMES IDENTIFICATION

The school nurse identifies expected outcomes for a plan individualized to the client or the situation.

Standard 4. PLANNING

The school nurse develops a plan that strategies and alternatives to attain expected outcomes.

Standard 5. IMPLEMENTATION

The school nurse implements the identified plan.

Standard 5a COORDINATION OF CARE

The school nurse coordinates care delivery.

Standard 5b HEALTH TEACHING AND HEALTH PROMOTION

The school nurse provides health education and employs strategies to promote
health and a safe environment.

Standard 5c CONSULTATION

The school nurse provides consultation to influence the identified plan, enhance the
abilities of others, and effect change.

81

Standard 5d PRESCRIPTIVE AUTHORITY AND TREATMENT

The advanced practice registered nurse uses prescriptive authority, procedures,
referrals, treatments, and therapies in accordance with state and federal laws and
regulations.

Standard 6. EVALUATION

The school nurse evaluates progress towards achievement of outcomes.

STANDARDS OF PROFESSIONAL PERFORMANCE
Standard 7. QUALITY OF PRACTICE

The school nurse systematically enhances the quality and effectiveness of nursing practice.

Standard 8. EDUCATION

The school nurse attains knowledge and competency that reflects current school nursing practice.

Standard 9. PROFESSIONAL PRACTICE EVALUATION

The school nurse evaluates one’s own nursing practice in relation to professional standards and
guidelines,
relevant status, rules, and regulations.

Standard 10. COLLEGIALITY

The school nurse interacts with, and contributes to the professional development of, peers and school
personnel
as colleagues.

Standard 11. COLLABORATION

The school nurse collaborates with the client, the family, school staff, and others in the conduct of
school
nursing practice.

Standard 12. ETHICS

The school nurse integrates ethical provisions in all areas of practice.

Standard 13. RESEARCH

The school nurse integrates research findings into practice.

Standard 14. RESOURCE UTILIZATION

The school nurse considers factors related to safety, effectiveness, cost, and impact on practice in the
planning
and delivery of school nursing services.

Standard 15. LEADERSHIP

The school nurse provides leadership in the professional practice setting and the profession.

Standard 16. PROGRAM MANAGEMENT

The school nurse manages school health services.
1

Refer to School Nursing: Scope & Standards of Practice for entire text.

Section A - 62 - 7-2007

DEPARTMENT OF EDUCATION
LICENSURE
For additional information on licensure as a Registered Nurse (R.N.), contact
the
Delaware Board of Nursing at 302-744-4515 or 302-744-4516 or
http://dpr.delaware.gov/boards/nursing/forms.shtml.
For additional information on licensure and certification as a school nurse,
contact
your district’s Human Resources Department or the Department of
Professional
Accountability Office at 302-735-4120. The Department of Education
brochure,
So You Want to be a School Nurse, is available on the Delaware School
Nurses
82

Association website.
Section A - 63 - 7-2007
14 DELAWARE CODE
1500 Professional Standards Board
1582 School Nurse

1.0 Content
This regulation shall apply to the requirements for a Standard Certificate for School
Nurses, pursuant to
14 Del.C. §1220(a).
2.0 Definitions
The following words and terms, when used in this regulation, shall have the
following meaning unless
the context clearly indicates otherwise:
"Department" means the Delaware Department of Education.
"Educator" means a public school employee who holds a license issued under the
provisions of 14
Del.C. c. 12, and includes teachers and administrators, and as otherwise defined by
the Standards Board
and the State Board pursuant to 14 Del.C. §1203, but does not include substitute
teachers. For the
purposes of this regulation, school nurses are considered educators.
"License" means a credential which authorizes the holder to engage in the practice
for which the
license is issued.
"Standard Certificate" means a credential issued to certify that an educator has the
prescribed
knowledge, skill or education to practice in a particular area, teach a particular
subject, or teach a
category of students.
"Standards Board" means the Professional Standards Board established pursuant to
14 Del.C. §1201.
"State Board" means the State Board of Education of the State pursuant to 14 Del.C.
§104.
3.0 Standard Certificate
In accordance with 14 Del.C. §1220(a), the Department shall issue a Standard
Certificate as a School
Nurse to a nurse who holds a valid Delaware Initial, Continuing, or Advanced
License; or a Limited
Standard, Standard or Professional Status Certificate issued by the Department prior
to August 31, 2003
and who meets the following requirements:
3.1 Bachelor's degree in Nursing or School Nursing from an accredited college or
university; and,
3.2 Current RN license, recognized by the DE Board of Nursing; and,
3.3 A minimum of three years clinical nursing experience; and
3.4 Valid and current certification in CPR.
4.0 Induction Requirements
4.1 Pursuant to 14 Del.C. §1510, 4.2 and 14 Del.C. §1511, 3.0, during the term of
the Initial License
83

as an educator, a school nurse must complete 90 clock hours of training consisting
of school
nursing, health education, testing and screening, counseling and guidance, and
introduction to
exceptional children. Failure to meet this requirement will result in the denial of a
Continuing
License. (See 14 Del.C. §1511, 3.0).
5.0 Revocation
5.1 A Standard Certificate; or a Limited Standard, Standard or Professional Status
Certificate as a
School Nurse issued prior to August 31, 2003 may be revoked in accordance with 14
Del.C.
§1514 for:
5.1.1 Making a materially false or misleading statement in a certificate application;
or
5.1.2 Revocation of a license issued under 14 Del.C. c.12; or
5.1.3 Failure to maintain a current license as a registered nurse in the State of
Delaware; or
5.1.4 Failure to maintain valid and current certification in CPR.

Section A - 64 - 7-2007
STATE OF
DELAWARE

Department of Education
Office of Certification
The Townsend Building, P.O. Box 1402
Dover, DE 19903
(302) 7399-4686

PRAXIS™ I Exemption Options
Effective July 1, 1996 the Delaware State Board of Education approved the following
Tests and Test Scores
as exemptions to the PRAXIS™ I Tests in reading, writing, and mathematics:
* Effective July 1, 1997, SAT Tests taken after 4/1/95 and presented for exemption must meet
the score indicated due to a recentering of the SAT.
PRAXIS™ I REQUIREMENTS EXEMPTION TESTS AND SCORE
Paper and Pencil Computer SAT VERBAL GRE VERBAL
Reading 175 322 480 490
* 560 (after 7/1/95)
range (150-190) (300-335) (200-800) (200-800)
SAT MATH GRE QUANTITATIVE
Math 174 319 520 540
* 540 (after 7/1/95)
range (150-190) (300-335) (200-800) (200-800)
NTE Communication Skills
Writing 173 319 670
range (150-190) (300-335) (600-695)

It is the intent of this policy to provide an option for individuals who have previously taken
other appropriate
standardized tests as indicated above, consequently, exemption test scores should pre-date
both application and
employment. It is not the intent of this policy to require that other tests be taken in lieu of
the PRAXIS™ I. The
PRAXIS™ I tests remain the State of Delaware testing requirement for initial certification.
All Exemption Test Scores shall be presented to the Office of Certification as “official” scores.
The following means of

84

score presentation are appropriate:
Test scores sent directly from Educational Testing Service to Delaware State Department of
Education. To send SAT
scores using Agency Code 9402, call (609) 771-7600. To send GRE scores using Agency Code
5154, call (609)
771-7670. Communication Skills scores are ordered using Agency Code R7065.
Unopened, untampered envelopes sent to the Delaware State Department of Education by
the individual.
Official college transcript showing appropriate test scores.
If an individual does not have the ability to provide official test scores, then the Exemption
Option cannot be exercised
and the appropriate PRAXIS™ I Test shall be taken.
NOTE: The Exemption Option may be exercised for any single PRAXIS™ I Test of Reading,
Writing, Mathematics, or
for all portions of the PRAXIS™ I Tests. Any portion for which the individual does not have or
meet the exemption
shall be presented by submitting the appropriate PRAXIS™ I Test.

Section A - 65 - 7-2007
A SCHOOL NURSE CERTIFICATE IN BASIC SCHOOL NURSING1
Approved by the Department of Education, State of Delaware, 11-2003

The School Nurse Certificate:
The Basic School Nursing cluster was specifically developed to address the
Department of Education
Induction requirements of the school nurse specialist. It integrates the 90-clock hour
requirement into a
comprehensive cluster. The goal is to provide newly licensed school nurses with
advanced knowledge and
skills needed to practice safely and effectively in the school setting.
Basic School Nursing aims to facilitate successful transition from general nursing
practice to school nursing
by addressing essential nursing and educational components that are needed by
school nurses, but are not
included in a traditional nursing degree program.
This cluster is approved by the Department of Education, State of Delaware. At the
completion of this
cluster, participants will receive a certificate in Basic School Nursing from the
University of Delaware.
The Curriculum:
90 hours – 4 modules (6 credits)
Delaware School Nurse Orientation Program – This component is held for one week
each August. Contact
Linda C. Wolfe, RN, MEd in the Department of Education at 302-735-4290.
Preventing Communicable Diseases in Children – This component focuses on
identification and prevention of
communicable diseases, the nurse as a first responder in a crisis situation involving
bioterrorism, as well
as measures taken to enhance protection and respond to active disease. It is offered
each fall.2
Issues in School Health Nursing (Nursing 667) – This 3-credit academic course is
offered each summer. It
focuses on the roles of the new school nurse and the healthcare needs of school-age
children. Content
85

includes: testing/screening, guidance/counseling, health teaching, legal and ethical
issues, and
community partnerships. Upon completion, 3 credits will be awarded.
To register, contact Continuing Education at 302-831-2741. Delaware Public School
Nurses are exempt
from tuition payment for summer credit course offerings. They only pay for
general/registration and text
fees. All other participants must pay the standing University tuition.
The Exceptional Child – This component focuses on the child with a chronic
condition with special needs. It
covers the federal laws that protect them, the principles of special education, and
multiple physical and
mental health conditions. It is offered each spring. 3 Upon successful completion of
the entire cluster, 45
nursing contact hours will be awarded.
For additional information, contact Dr. Janice Selekman at [email protected] or
302-831-1256 or Linda C.
Wolfe, RN at [email protected] or 302-735-4290. A copy of the Basic School
Nursing Cluster brochure
is available on the Delaware School Nurses Association website.
Information taken from University of Delaware brochure, 12-2004.
Register through the University of Delaware, Department of Nursing , at 302-831-0003
($250 each).
3 Register through the University of Delaware, Department of Nursing , at 302-831-0003
($250 each).
1
2

Section A - 66 - 7-2007
GUIDELINES FOR RENEWAL OF A CONTINUING LICENSE
Department of Education
Office of Professional Accountability
401 Federal Street, Suite 2
Dover, DE 19901
www.doe.k12.de.us
A three-tiered licensure system is established for Delaware educators, which
includes school nurses.
In accordance with statute (14 Del Code, Chapter 12), regulations governing
the educator license
system were developed by the Professional Standards Board and approved
by the State Board of
Education.
The Department of Education is responsible for the implementation of the
licensure system. A
Continuing License will be issued to all Delaware educators who hold
standard or professional status
certificates, as those certificates are renewed. A Continuing License is valid
for five years and is
renewable. Procedures for non-public educators are provided through
Regulation 278 Non-Public
School Educator Licensure and Certification.
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The Continuing License Manual describes the requirements and guidelines
for license renewal,
including frequently asked questions, renewal options and procedures.
Section B -1- 7-2007

Section B.
School Entry &
Maintenance
I. Foundations of School Nursing
II. Documentation Requirements
III. School Entry
a. Immunization
b. Tuberculosis
c. Physical examination
d. Lead
IV. Screenings
a. Vision
b. Hearing
c. Postural & Gait
V. Medications
a. Prescriptions
b. OTC
c. Field trips

The information in Section B provides guidelines on some fundamentals of school
nursing practice in
Delaware. A quality documentation system assures easy input and access of
information, continuity
of care, transfer of records confidentially, and accuracy. School enrollment health
requirements also
support the health and well being of the student by providing a current and
accurate assessment.
Both documentation and data collection help to assure that each student’s
individual needs are
considered when planning for full school participation and academic success.
Regulations must be
followed as specifically written, but additional protocols and policies may be needed
in order to
assure safe practice within an individual school setting or for an individual student.
For example, the
regulation on field trips provides structure for allowing teacher assistance with selfmedication;
however, in some cases the best management may be to have a school nurse
accompany the student.

Section B - 2 - 6-2005

87

I. Foundations of School Nursing
Section B - 3 - 6-2005
School Nurse Responsibilities*
The school nurse should have the physical, mental, social, emotional and
ethical capabilities,
as well as the professional nursing and other educational preparation, to
adequately perform
in the following areas:
1. The school nurse provides health care to the school community.
• To assume responsibility for the care of the sick and injured in keeping with
school
policy.
2. The school nurse provides leadership for the provision of health services.
• To maintain adequate and up-to-date health records.
• To evaluate the nursing aspects of the school health program.
3. The school nurse provides screening and referral for health conditions.
• To appraise and identify the health needs of students through school
screenings such
as vision, hearing, postural/gait, tuberculin testing and physical
examinations.
• To encourage the correction of remedial conditions by working with
parents/guardians, teachers and community agencies.
4. The school nurse promotes a healthy school environment.
• To work with administrators, teachers, and other school personnel to
modify the
school environment and curriculum for children with health concerns.
• To recommend changes in the school environment to reduce health and
safety
hazards.
5. The school nurse promotes health.
• To provide health counseling to students, parents/guardians and school
personnel,
keeping in mind the limitations as well as abilities.
• To present health education, both informally and formally, as requested.
6. The school nurse serves in a leadership role for health policies and
programs.
• To serve as a resource person to the school and the community on health
education
including, but not limited to, physical, emotional, personal and social, and
consumer
health and safety.
• To review and evaluate own job performance and professional
development.
7. The school nurse serves as a liaison between school personnel, family,
community, and
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health care providers.
• To serve as liaison between the healthcare community and the schools.

The nurse is a member of the school’s professional staff
and
contributes to the total educational program.
* The seven major roles are identified within the Issue Brief of the National Association of School
Nurses, School Health
Nursing Services Role in Health Care, Role of the School Nurse (2002).

Section B - 4 - 6-2005
Suggested Schedule for the School Nurse
August – October
Prior to the first student day:
1. Set up health room with medical supplies and equipment.
2. Review Standard Precautions with staff.
3. Organize Student Health Records in a manner that allows easy access; i.e., arrange by
homeroom, grade
level, or alphabetical order. (Get current pupil roster from school office.)
4. Review health records to identify students with special health concerns or those needing
immunizations,
tuberculosis screening, physical exams or lead testing. Communicate with appropriate
school personnel
regarding student health conditions and any needed school modification.
During the first week of school:
5. Carry out responsibilities related to staff and/or volunteer tuberculosis screening as
directed by district.
6. Obtain Emergency Data Cards on all students; maintain in nurse’s office for easy access.
7. Organize medication and treatment administration.
8. Obtain health records for students transferring into school; if it is believed no record will
be forthcoming,
obtain data and start record. Forward health records for students transferring out of schools.
After the start of the school year:
9. Update health records with information obtained from Student Health History Update.
10. Send copies of School Immunization Form or computer print out of new school enterers’
immunizations to
the Division of Public Health Immunization Program.
11. Identify students eligible for dental clinic services, process parental permission slips,
schedule visits to
clinic, and arrange for transportation of students (if available).
12. Prepare schedule and begin screening programs. Postural/gait screening should be
completed prior to
December 15 of each year and reported to the District Liaison/Coordinator. Hearing and
vision screening
should be completed by January 15.
13. Continue contacts with parent/guardian of students needing a physical examination,
tuberculin screening,
immunizations or lead testing.
14. Inform teachers assigned to health instruction of resources and materials available
through your office or
state and local agencies.
15. Inform parents regarding scheduled, mandated screenings.

January – April
1. Order supplies and equipment for next school year.

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2. Assist with kindergarten registration as directed by district.

May – June
1. Prepare District/Charter Summary of School Health Services (See Section B, page 29) and
send to district
office by designated date.
2. Prepare health records for transfer to feeder school or state archives.
3. Follow up on referrals.

Ongoing Responsibilities – September through June
1. Check and re-supply medical supplies in nurses’ office.
2. Continue with screening, recording, and follow-up with parent/guardian and school staff.
3. Continue to serve as a resource person for health education in classrooms.
4. Continue conferences with teachers to keep nurse and teachers abreast of any health
concerns that may
surface.
5. Check absentee lists for clues leading to epidemics. The school nurse is not an attendance
officer or clerk
but should utilize expertise in working with absences related to illness.
6. Continue record review, update and follow-up as needed.
7. Continue to follow up with parent/guardian who fail to respond to referrals.
8. Prepare and monitor individual healthcare plans and individual emergency care plans for
students with
special needs.
9. Continue to assess records of new enterers.
10. Organize/facilitate athletic physical examinations as requested /directed.
11. Participate in IEPs and multi-disciplinary meetings PRN.
12. Provide instruction to school personnel who will be responsible for assisting with
medication on field trips.
13. Provide/arrange pertinent inservice programs for staff.

Section B -5- 7-2007

Confidentiality of School Health Information
Confidentiality of student health information is governed by local, state and
federal
legislation. The school nurse must carefully assess every situation before
sharing any student
information on a “need to know” basis.
Federal statutes and regulations have jurisdiction over privacy in school
records: the Family
Educational Rights and Privacy Act (FERPA), the Individuals with Disabilities
Education
Act (IDEA), and Section 504 of the Americans with Disabilities Act (ADA).
Department of
Education Regulation #250, Procedures Related to the Collection,
Maintenance and
Disclosure of Student Data, delineates school responsibilities related to
student records.
Additionally, Department of Education Regulation #925, Children with
Disabilities, provides
guidelines. It should be noted that the Health Insurancy Portability of
Accountability Act

90

(HIPPA) regulates the sharing and transfer of medical data in medical
settings, while FERPA
governs educational records including student health data. Regulation #251,
Family
Educational Rights & Privacy Act (FERPA), delineates Delaware School
responsibilities.
The school nurse is bound by the Code of Ethics of the National Association
of School
Nurses to respect confidentiality. Licensure as a registered nurse carries that
same obligation
and accountability.
It is highly recommended that the school nurse become familiar with
confidentiality
regulations as outlined in FERPA, IDEA, Section 504 of the ADA and state law.
An
additional resource is Guidelines for Protecting Confidential Student Health
Information
written by the National Task Force on Confidential Student Health
Information, a project of
the American School Health Association in collaboration with the National
Association of
School Nurses and the National Association of School Nurse Consultants.
Section B - 6 - 6-2005

II. Documentation Requirements
Section B -7- 7-2007
811 School Health Record Keeping Requirements
1.0 Definitions
“Delaware School Health Record Form” means a form containing documentation of an
student’s
health information, which includes but is not limited to identifying information, health
history,
immunizations, results of mandated testing and screenings, medical diagnoses, long term
medications
and referrals.
“Emergency Treatment Card” means a card containing general school emergency
procedures for
the care of a student who becomes sick or injured at school. The card contains the following
information: the student's name, birth date, school district, school, grade, home room or
teacher,
home address, home telephone, the name, place of employment and work telephone of the
parent,
guardian or Relative Caregiver; two other names, addresses and phone numbers of
individuals who
can be contacted at times when the parent, guardian or Relative caregiver can not be
reached; the
name and telephone number of the family physician and family dentist; any medical
conditions or
allergies the student has; and the student's medical insurance.

91

2.0 Emergency Treatment Card
2.1 An Emergency Treatment Card for each public school student shall be on file in the office
of
the school nurse.
2.1.1 The information on the Emergency Treatment Card shall be shared only on a
need to know basis as related to the education and health needs of the student
and consistent with state and federal laws.
2.1.2 The parent, guardian or Relative Caregiver or the student if 18 years or older, or
an unaccompanied homeless youth (as defined by 42 USC 11434a) shall sign
the Emergency Treatment Card to assure they understand the purpose of the
form and acknowledge the accuracy of the information.
3.0 Delaware School Health Record Form
3.1 The Delaware School Health Record Form shall be current and shall be part of the
student’s
health record within the Cumulative Record File (14 DE Admin. Code 252) which
accompanies the student when he or she moves to another school.
3.2. The Delaware School Health Record Form shall be maintained for the duration of the
student's schooling and the school nurse shall use the Student Health History Update Form
to keep health records current.
The Delaware School Health Record Form shall remain in the nurse's file during the
student's attendance in school.
3.2.1 The Delaware School Health Record Form may be maintained in hard copy or within
an electronic documentation program and transferred electronically. Beginning with
the 2008-2009 school year, all Delaware School Health Records Forms shall be in an
electronic format.
NON REGULATORY NOTE: also see 14 DE Admin. Code 251 and 252 and the Delaware Public
Archives Document Delaware School Districts General Records Retention Schedule.
4.0 Other Required Documentation
4.1 The school nurse shall document any nursing care provided including the school name, a
three point date, the person's (student, staff or visitor) first and last name, the time of arrival
and departure, the presenting complaint, the nurse's assessment intervention and the
outcome, the disposition of the situation, the parent or other contact, if appropriate, and the
nurse's complete signature or initials.
4.1.1 The school nurse shall document the care given at the time of a school based
accident by completing the Student Accident Report Form if the student missed more than
one half day because of the accident or if the school nurse has referred the student for a
medical evaluation regardless of whether the parent, guardian or Relative Caregiver or
student if 18 years or older, or an unaccompanied homeless youth (as defined by 42 USC
11434a) followed through on that request.
5.0 Submission of Records
5.1 All local school districts and charter schools shall submit the Summary of School Health
Services Form, to the Delaware Department of Education by August 31st of each year. The
form shall include all of the school health services provided in all schools during the fiscal
year including summer programs.

Section B - 8 - 6-2005
DELAWARE EMERGENCY TREATMENT DATA CARD
Student's Name Birth Date School District
Last Name First Name M.I.
School Grade Homeroom or Teacher Bus No.
Home Address Development Home Phone
Resides with Relationship
Mother/Guardian's Name Father/Guardian's Name
Mother's Place of Employment Phone Ext.
Father's Place of Employment Phone Ext.
Pager number Cellular number
If parents/guardians cannot be reached, call:

92

1.
Name Address Phone
2.
Name Address Phone
3.
Name Address Phone
Family Physician Phone Family Dentist Phone
Indicate student's serious medical conditions
Student is allergic to: ( ) Penicillin ( ) Aspirin ( ) Other
Medical Insurance: Medicaid No. Other:
Certificate No. Group No. Type

This information may be shared only on a “need to know” basis with school personnel and emergency
medical staff.

-----------------------------------------------------------------------------SCHOOL EMERGENCY PROCEDURES
Your schools have adopted the following procedures in caring for a student when he/she becomes sick
or injured at school:
In case of a life-threatening emergency, the school will call 911 and then follow the steps below. In
case of
other emergencies and/or need of medical or hospital care:
1. The school will call the home. If there is no answer,
2. The school will call the father's, mother's or guardian's place of employment. If there is no answer,
3. The school will call the other telephone number(s) listed and the physician.
4. If none of the above answer, the school will call an ambulance, if necessary, to transport the student
to a
local medical facility.
5. Based upon the medical judgment of the attending physician, the student may be admitted to a
local
medical facility.
6. The school will continue to call the parents, guardians, or physician until one is reached.
If I cannot be reached and the school authorities have followed the procedures described, I agree to
assume all expenses for
moving and medically treating this student. I also hereby consent to any treatment, surgery, diagnostic
procedures or the
administration of anesthesia which may be carried out based on the medical judgment of the attending
physician.
Parent/Guardian Signature Date

Section B - 9 - 6-2005
Last Name First and Middle Name M F Date of Birth

*

SCHOOL HEALTH RECORD – STATE OF DELAWARE
Parent/Guardian Name:
Medical Alert
(Chronic illness, Injury, Surgery, with Date; example: 4/98 Asthma)

School Student is Attending
(Record School Number)
Pre-KN KN 1 2 3 4 5 6 7 8 9 10 11 12

Immunizations
(May attach State Form)
Exempt Type 1 2 3 4 5 6

DTP/DtaP
OPV/IPV
Hep B
Measles
Mumps
Rubella
HIB
Varicella
Other

93

Testing
Date Test Type (circle one) Results Initials Date Test Type (circle one) Results Initials

TB PPD/Risk Assess Lead Blood
Physical Examinations
(Documentation in Student’s File)
Date Significant Findings Date Significant Findings

Long-term Medications
Name Start Stop Name Start Stop

School Nurse Name and Initials
*Color Code
BLACK – Neuro BLUE - Respiratory GREEN – Ortho ORANGE – Allergies, Other PINK - Kidney RED - Cardiac YELLOW –
Vision
Document #

Section B - 10 - 6-2005
Student Name: (Last) (First)
Screening Results
Vision Screening

(Record Actual Acuity, ex: 20/20, 10/10, etc.)

Color Test Date:_______________ ___Pass ___Fail
Depth Perception Date:__________ ___Pass_ __Fail
Grade

Date
Device
Acuity: Far R
L
Both
Near R
L
Both
Glasses/Contacts
Muscle Balance
Initials
Hearing Screening
(P = Pass; F = Fail)

Grade

Date
Decibels
R 1000
2000
4000
L 1000
2000
4000
Aid
Initials
Postural Screening Other Information
(Ex: Comments, Conferences, etc)

Grade

Phase I Date
Results
Phase II Date
Initials
Referral Information

(Follow Up for Screenings Only)
Issue/Concern Date Sent Follow-up

Summary Issue/Concern

Date Sent

Section B - 11 - 6-2005
Student Name: (Last) (First)
Delaware School Health Record

94

Follow-up Summary

Additional Notes
Date Conferences, Comments, Etc.
STATE OF DELAWARE
INDIVIDUAL HEALTH SERVICES LOG

District/School:
_____________________________________________________________________________________________
______________________
School Nurse: __________________________________________________
_______________________________________________________________

(printed name / signature / initials) (printed name / signature / initials)
Category: ILA - Illness:Acute INS – Injury:School Rx - Medication M – Miscellaneous
ILC – Illness:Chronic INO – Injury:Outside of school C – Catheterization C – Conference
INON – Injury:On-going care T – Tube feeding, ostomy, other P – Special Procedure S – Screening

Medical Alerts: _________________________________ Birth Date: ____________
Student: ________________________________________
Date In/Out Class/
Grade

Reason
(Category/Chief Complaint)

Intervention/ Comments Outcome Rx/Tx Referral
(to
whom/complete)

Initials

Section B - 13 - 6-2005
STATE OF DELAWARE
CHILDREN’S SERVICES COST RECOVERY PROJECT LOG
EPSDT Nursing Service Description by Medicaid Reporting Number
Date: ____/_____/______ District/School:
School Nurse:
Signature(s) Required (Initial below if more than one nurse)
EPSDT
Reporting
Number

Time
In
Time
Out
Student Name
Document #229
Section B - 14 - 6-2005
Children’s Services Cost Recovery Project (CSCRP)
EPSDT Nursing Service Description by Medicaid Reporting Number
Nursing Service Description: Treatment
1 Care of the Sick
2 Wound Care – First Aid
3 Wound Care – Ongoing
4 Collateral Contacts for Updating Medical Information: Community Agencies,
Doctors, Staff, Family
5 Medications – Administration & Monitoring
6 Physician Prescribed Medical Treatments
7 Nursing Evaluation
95

8 Diabetic Care – Monitoring and/or Medication Administration
9 Cast Care
10 Personal Care, which is Medically Necessary and Requires Nurse Intervention
11 Naso-gastric Feedings – Bolus/Drip
12 Gastrostomy Feedings – Bolus/Drip
13 Change of Gastrostomy Tube
14 Catheterization
15 Feeding of Children with Oral Motor Deficits
Speech Pathology/Occupational Therapy
16 Suctioning
17 Tracheal Suctioning
18 Tracheal Care – Decanulation
19 Tracheal Ventilation – Ambu Bag
20 Oxygen Administration
21 Nebulizing/Humidifying
22 Postural Drainage
23 Chest Percussion
24 Special Diet Consideration: Modification & Monitoring
N/A Child was Medicaid Recipient, But Non-EPSDT Service or Nurse Judged Service
not
Medically Necessary
Number Nursing Service Description: Assessment
A1 EPSDT Partial Assessment: Health Education
A2 EPSDT Partial Assessment: Immunization
A3 EPSDT Assessment: Hearing
A4 EPSDT Assessment: Vision
A5 EPSDT Partial Assessment: Developmental/Orthopedic
A6 EPSDT Assessment: Dental
Number Nursing Service Description: Counseling Therapy
C1 Individual Counseling Treatment
C2 Group Counseling Treatment
C3 Family Counseling Treatment
C4 Individual Counseling Co-Treatment
C5 Group Counseling Co-Treatment
C6 Family Counseling Co-Treatment
C7 Case Consultation

Document #229
NURSING INTERVENTION CLASSIFICATION©
Section B - 15 - 6-2005
NURSING CARE

Admission Care ADMINCARE – facilitating entry of student into school (health needs)
Airway Management AIRMGT–facilitation of patency of air passages
Airway Suctioning AIRSUC–removal of airway secretions by inserting a suction catheter into the
patient’s oral airway &/or trachea
Allergy Management ALLERGY–identification, treatment, & prevention of allergic responses to
food, medications, insect bites, contrast material, blood, & other substances
Artificial Airway Management ARTAIR–maintenance of endotrachial/tracheostomy tubes &
prevention of complications associated with their use
Aspiration Precautions ASPIR–prevention/minimization of risk factors in the patient at risk for
aspiration
Asthma Management ASTHMA–identification, treatment and prevention of reactions to
inflammation/constriction of the airway passages

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Bleeding Reduction: Nasal NOSEBL– Limitation of blood loss from the nasal cavity
Bleeding Reduction: Wound BLEED–limitation of the blood loss from a wound that may be a
result of trauma, incisions, or placement of a tube or catheter
Bowel Management BWL–establishment & maintenance of a regular pattern of bowel elimination
Cast Care: Maintenance CAST–care of a cast after the drying period
Chest Physiotherapy CHEST–assisting the patient to move airway secretions from peripheral
airways to more central airways for expectoration &/or suctioning
Diarrhea Management DIARR–prevention & alleviation of diarrhea
Emergency Care (illness) ERILL–providing life-saving measures in life-threatening situations
caused by illness
Emergency Care (injury) ERINJ–providing life-saving measures in life-threatening situations
caused by injury
Enteral Tube Feeding TUBEFEED–delivering nutrients & water through a gastrointestinal tube
Feeding FEED – feeding of patient with oral motor deficits
Fever Treatment FVR–management of a patient with hyperpyrexia caused by nonenvironmental
factors
First Aid WOUNDFA–providing initial care for a minor injury
Health Care Information Exchange (illness) INFOILL–providing patient care information to
other health professionals related to illness
Health Care Information Exchange (injury) INFOINJ–providing patient care information to
other health professionals related to injury
Heat/Cold Application (injury) HTCLD–stimulation of the skin & underlying tissues with heat or
cold for the purpose of decreasing pain, muscle spasms, or inflammation
Heat Exposure Treatment HEATX–management of patient overcome by heat due to excessive
environmental heat exposure
Hemorrhage Control HMRR–reduction or elimination of rapid & excessive blood loss
High-Risk Pregnancy Care PREG–identification & management of a high-risk pregnancy to
promote healthy outcomes for mother & baby
Hyperglycemia Management HYPERG–preventing & treating above-normal blood glucose
levels
Hypoglycemia Management HYPOG–preventing & treating low blood glucose levels
Medication Administration MEDADM–preparing, giving, & evaluating the effectiveness of
prescription & nonprescription drugs
Medication Management MEDMGT–facilitation of safe/effective use of prescription & over-thecounter
drugs
Multidisciplinary Care Conference (illness) CONFILL–planning & evaluating patient care with
health professionals from other disciplines
Multidisciplinary Care Conference (injury) CONFINJ–planning & evaluating patient care with
health professionals from other disciplines
Neurologic Monitoring NEURO–collection & analysis of patient data to prevent or minimize
neurological complications
Non-Nursing Intervention NONNURSE – providing service not requiring nursing skills/expertise
Nursing Intervention NURSE – intervention requiring professional nursing knowledge and skills
(not available on current list)
Nutrition, Special Diet SPDIET–modification & monitoring of special diet
Ostomy Care OSTO– maintenance of elimination through a stoma & care of surrounding tissue
Pain Management PAIN–alleviation of pain or a reduction in pain to a level of comfort that is
acceptable to the patient
Positioning POSI–deliberative placement of the patient or a body part to promote physiological
&/or psychological well-being
Referral Management REFMGT – arrangement for services by another healthcare provider or
agency
Respiratory Monitoring RESP–collection & analysis of patient data to ensure airway patency &
adequate gas exchange
Rest REST – providing environment & supervision to facilitate rest/sleep after nursing evaluation
Resuscitation RESUS–administering emergency measures to sustain life
Seizure Management SZR–care of a patient during a seizure & the postictal state
Self-Care Assistance, Nursing SELFNUR–assisting another to perform activities of daily living
Self-Care Assistance, Non-Nursing SELFNON–assisting another to perform activities of daily

97

living

Skin Care SKIN–application of topical substances or manipulation of devices to promote skin

integrity & minimize skin breakdown
Surveillance SURV - purposeful/ongoing acquisition, interpretation, & synthesis of patient data for
clinical decision making
Surveillance: Skin SKINSRV–collection/analysis of patient data to maintain skin & mucous
membrane integrity
Telephone Consultation TC–for purpose of updating medical information
Treatment Administration TXADM–preparing, giving, & evaluating the effectiveness of
prescribed treatments
Treatment Management TXMGT–facilitation of safe & effective prescribed treatments
Tube Care TUBECARE–management of a patient with an external drainage device exiting the
body
Tube Care, Gastrointestinal TUBECAREGI–management of a patient with a gastrointestinal
tube
Urinary Catheterization CATH–insertion of a catheter into the bladder for temporary or
permanent drainage of urine
Vital Signs Monitoring VS–collection/analysis of cardiovascular, respiratory, & body temperature
data to determine/prevent complications
Wound Care (Ongoing) WOUNDON–prevention of wound complications & promotion of wound
healing

NURSING INTERVENTION CLASSIFICATION©
Section B - 16 - 6-2005
COUNSELING

Abuse Protection Support: Child ABUSE – identification of high-risk, dependent child
relationships & actions to prevent possible or further infliction of physical, sexual, or
emotional harm or neglect of basic necessities of life
Counseling (individual) COUNSEL – use of an interactive helping process focusing on the
needs, problems, or feelings of the patient & significant others to enhance or support
coping, problem-solving, & interpersonal relationships
Counseling (group) COUNSELG – use of an interactive helping process focusing on the
needs, problems, or feelings of the group & significant others to enhance or support
coping, problem-solving, & interpersonal relationships

HEALTH EDUCATION

Anticipatory Guidance (individual) AGUIDE – preparation of patient for an anticipated
developmental &/or situational crisis
Anticipatory Guidance (group) AGUIDEG – preparation of a group of patients for an
anticipated developmental &/or situational crisis
Body Mechanics Promotion (individual) BODY – facilitating a patient in the use of posture &
movement in daily activities to prevent fatigue & musculoskeletal strain or injury
Body Mechanics Promotion (group) BODYG – facilitating a group of patients in the use of
posture & movement in daily activities to prevent fatigue & musculoskeletal strain or injury
Exercise Promotion (individual) EXER – facilitation of a patient in regular physical exercise
to maintain or advance to a higher level of fitness & health
Exercise Promotion (group) EXERG – facilitation of a group of patients in regular physical
exercise to maintain or advance to a higher level of fitness & health
Health Education (individual) HLTHED – developing & providing individual instruction &
learning experiences to facilitate voluntary adaptation of behavior conducive to health in
individuals, families, groups, or communities
Health Education (group) HLTHEDG – developing & providing group instruction & learning
experiences to facilitate voluntary adaptation of behavior conducive to health in
individuals, families, groups, or communities
Smoking Cessation Assistance (individual) SMOKE – helping the patient to stop smoking
through an individual process
Smoking Cessation Assistance (group) SMOKEG – helping the patient to stop smoking in a
group process
Substance Use Prevention (individual) SUBAB – prevention of an alcoholic or drug use lifestyle
through an individual process

98

Substance Use Prevention (group) SUBABG – prevention of an alcoholic or drug use lifestyle
through a group process
Weight Management WGTMGT – facilitating maintenance of optimal body weight & percent
body fat

HEALTH PROMOTION/PROTECTION

Environmental Management ENVMGT – manipulation of the patient’s surroundings for
therapeutic benefit, sensory appeal & psychological well-being
Health System Guidance HGUIDE – facilitating a patient’s location & use of appropriate
health services
Infection Protection INFPRO – prevention & early detection of infection in a patient at risk
Progressive Muscle Relaxation MURELX – facilitating the tensing & releasing of successive
muscle groups while attending to the resulting differences in sensation
Seizure Precautions SZRPRE – prevention or minimization of potential injuries sustained by a
patient with a known seizure disorder
Suicide Prevention PRESUI – reducing risk of self-inflicted harm with intent to end life
Surveillance: Safety SAFE – purposeful & ongoing collection & analysis of information about
the patient & the environment for use in promoting & maintaining patient safety
Sustenance Support SUST – helping a needy individual/family to locate food, clothing, or
shelter

SCREENING

Health Screening: BMI SCREENBMI – monitoring growth and detecting abnormalities
through height and weight measurement
Health Screening: Blood Pressure SCREENBP – detecting possible hypertension through
BP measurement
Health Screening: Dental SCREENDEN – detecting possible dental abnormalities through a
dental exam of the mouth using a dental instrument
Health Screening: Developmental SCREENDEV – detecting possible developmental or
orthopedic deviations through history & screening
Health Screening: Hearing SCREENH – detecting possible hearing deviations through
screening measures
Health Screening: Immunization SCREENI – determining immunization status & compliance
by means of history, examination, & other procedures
Health Screening: Other SCREENOT – detecting abnormalities/deviations through the use of
standardized screening methods
Health Screening: Pediculosis SCREENPEDIC– detecting the presence of lice or nits
through examination
Health Screening: Postural/Gait SCREENPG – detecting possible postural or gait deviations
through screening measures
Health Screening: Tuberculosis SCREENTB – detecting possible exposure to TB through
the use of a health risk assessment questionnaire
Health Screening: Vision SCREENV – detecting possible vision deviations through screening
measures

Section B - 17 - 6-2005
NIC links to CSCRP

Nursing Intervention - #1 – Care of the Sick
Airway Management – facilitation of patency of air passages
Allergy Management – identification, treatment, and prevention of allergic responses to food,
medications,
insect bites, contrast material, blood, or other substances
Aspiration Precautions – prevention or minimization of risk factors in the patient at risk for
aspiration
Asthma Management – personal actions to reverse inflammatory condition resulting in
bronchial
constriction of the airways
Body Mechanics Promotion (individual) – facilitating the use of posture and movement in
daily activities

99

to prevent fatigue and musculoskeletal strain or injury
Bowel Management – establishment and maintenance of a regular pattern of bowel
elimination
Diarrhea Management – prevention and alleviation of diarrhea
Emergency Care (illness) – providing life-saving measures in life-threatening situations
Fever Treatment – management of a patient with hyperpyrexia caused by nonenvironmental
factors
Heat Exposure Treatment – management of patient overcome by heat due to excessive
environmental heat
exposure
Pain Management – alleviation of pain or a reduction in pain to a level of comfort that is
acceptable to the
patient
Resuscitation – administering emergency measures to sustain life
Seizure Management – care of a patient during a seizure and the postictal state

Nursing Intervention - #2 – Wound Care – First Aid
Bleeding Reduction: Nasal – limitation of the amount of blood loss from the nasal cavity
Bleeding Reduction: Wound – limitation of the blood loss from a wound that may be a result
of trauma,
incisions, or placement of a tube or catheter
Emergency Care (injury) – providing life-saving measures in life-threatening situations
First Aid – providing initial care of a minor injury
Heat/Cold Application – stimulation of the skin and underlying tissues with heat or cold for
the purpose of
decreasing pain, muscle spasms, or inflammation
Hemorrhage Control – reduction or elimination of rapid and excessive blood loss

Nursing Intervention - #3 – Wound Care – Ongoing
Ostomy Care – maintenance of elimination through a stoma and care of surrounding tissue
Wound Care (Ongoing) – prevention of wound complications and promotion of wound healing

Nursing Intervention - #4 – Collateral Contacts for Updating Medical Information:
Community Agencies, Doctors, Staff, Family
4-1 Health Care Information Exchange (illness) – providing patient care information to health
professionals in other agencies
4-2 Health Care Information Exchange (injury) – providing patient care information to health
professionals in other agencies
4-1 Multidisciplinary Care Conference (illness) – planning and evaluating patient care with
health
professionals from other disciplines
4-2 Multidisciplinary Care Conference (injury) – planning and evaluating patient care with
health
professionals from other disciplines
4-1 Telephone Consultation – for purpose of updating medical information

Nursing Intervention - #5 – Medications – Administration & Monitoring

Medication Administration – preparing, giving, and evaluating the effectiveness of
prescription and
nonprescription drugs
Medication Management – facilitation of safe and effective use of prescription and over-thecounter drugs

Nursing Intervention - #6 – Prescribed Treatments

Section B - 18 - 6-2005

Treatment Administration – preparing, giving, and evaluating the effectiveness of prescribed
treatments
(DE)
Treatment Management – facilitation of safe and effective prescribed treatments (DE)

100

Nursing Intervention - #7 – Nursing Evaluation
Health Screening: Blood Pressure - detecting possible hypertension through blood
measurement
7-7 Health Screening: BMI – detecting possible abnormalities through height and weight
calculations of
BMI
7-7 Health Screening: Other – detecting abnormalities and/or deviations through the use of
standardized
screening methods
Health Screening: Pediculosis – detecting the presence of lice or nits through examination
Health Screening: Tuberculosis - detecting possible exposure to tuberculosis through the use
of a health
risk assessment questionnaire
High-Risk Pregnancy Care – identification and management of a high-risk pregnancy to
promote healthy
outcomes for mother and baby
Neurologic Monitoring – collection and analysis of patient data to prevent or minimize
neurological
complications
Nursing Intervention – intervention requiring professional nursing knowledge and skills (not
available on
current list)
Respiratory Monitoring – collection and analysis of patient data to ensure airway patency
and adequate
gas exchange
Rest – providing environment and supervision to facilitate rest/sleep after nursing evaluation
Skin Surveillance – collection and analysis of patient data to maintain skin and mucous
membrane integrity
Surveillance – purposeful and ongoing acquisition, interpretation, and synthesis of patient
data for clinical
decision making
Vital Signs Monitoring – collection and analysis of cardiovascular, respiratory, and body
temperature data
to determine and prevent complications

Nursing Intervention - #8 – Diabetic Care – Monitoring &/or Medication
Administration
Hyperglycemia Management – preventing and treating above-normal blood glucose levels
Hypoglycemia Management – preventing and treating low blood glucose levels

Nursing Intervention - #9 – Cast Care
Cast Care: Maintenance – care of a cast after the drying period

Nursing Intervention - #10 – Personal Care, which is Medically Necessary and
Requires
Nurse Intervention
Positioning – deliberative placement of the patient or a body part to promote physiological
and/or
psychological well-being
Progressive Muscle Relaxation – facilitating the tensing and releasing of successive muscle
groups while
attending to the resulting differences in sensation
Self-Care Assistance, Nursing – assisting another to perform activities of daily living
Skin Care – application of topical substances or manipulation of devices to promote skin
integrity and
minimize skin breakdown
Tube Care – management of a patient with an external drainage device exiting the body

101

Nursing Intervention - #11 – Naso-gastric Feedings – Bolus/Drip
Nursing Intervention - #12 – Gastrostomy Feedings – Bolus/Drip
Enteral Tube Feeding – delivering nutrients and water through a gastrointestinal tube

Nursing Intervention - #13 – Change of Gastrostomy Tube
Tube Care, Gastrointestinal – management of a patient with a gastrointestinal
tube

Section B - 19 - 6-2005
Nursing Intervention - #14 – Catheterization
Urinary Catheterization – insertion of a catheter into the bladder for temporary or permanent
drainage of
urine

Nursing Intervention - #15 – Feeding

Feeding – feeding of patient with oral motor deficits (DE)

Nursing Intervention - #16 – Suctioning
Airway Suctioning – removal of airway secretions by inserting a suction catheter into the
patient’s oral
airway and/or trachea

Nursing Intervention - #17 – Tracheal Suctioning
Nursing Intervention - #18 – Tracheal Care - decannulation

Artificial Airway Management – maintenance of endotrachial and tracheostomy tubes and
prevention of
complications associated with their use

Nursing Intervention - #19 – Tracheal Ventilation – Ambu Bag
Nursing Intervention - #20 – Oxygen Administration
Nebulizing/Humidifying - #21
Nursing Intervention - #22 – Postural Drainage
Chest Physiotherapy – assisting the patient to move airway secretions from peripheral
airways to more
central airways for expectoration and/or suctioning

Nursing Intervention - #23 – Chest Percussion
Nursing Intervention - #24 – Special Diet Consideration: Modification & Monitoring
Nutrition, special diet – modification and monitoring of special diet

Nursing Intervention – C1 – Individual Counseling Treatment
Counseling (individual) – use of an interactive helping process focusing on the needs k
problems, or feeling
of the patient and significant others to enhance or support coping, problem-solving, and
interpersonal
relationships
Exercise Promotion (individual) – facilitation of regular physical exercise to maintain or
advance to a
higher level of fitness and health

Nursing Intervention – C2 – Group Counseling Treatment
Counseling (group) – use of an interactive helping process focusing on the needs k problems,
or feeling of
the patient and significant others to enhance or support coping, problem-solving, and
interpersonal
relationships
Exercise Promotion (group) – facilitation of regular physical exercise to maintain or advance
to a higher
level of fitness and health

Nursing Intervention - #A1 – Health Education
Health Education (individual) – developing and providing instruction and learning
experiences to facilitate

102

voluntary adaptation of behavior conducive to health in individuals, families, groups, or
communities
Smoking Cessation Assistance (individual) – helping another to stop smoking
Substance Use Prevention (individual) – prevention of an alcoholic or drug use life-style
Weight Management – facilitating maintenance of optimal body weight and percent body fat

Nursing Intervention - #A2 – Immunization

Section B - 20 - 6-2005

Health Screening: Immunization – determining immunization status and compliance by
means of history,
examination, and other procedures (DE)

Nursing Intervention - #A3 – Hearing

Health Screening: Hearing – detecting possible hearing deviations through screening
measures (DE)

Nursing Intervention - #A4 – Vision

Health Screening - Vision – detecting possible vision deviations through screening measures
(DE)

Nursing Intervention - #A5 – Developmental/Orthopedic

Health Screening: Developmental – detecting possible developmental or orthopedic
deviations through
history and screening (DE)
Health Screening: Postural/Gait – detecting possible postural or gait deviations through
screening
measures
Nursing Intervention - #A6 – Dental
Health Screening: Dental – detecting possible dental abnormalities through a dental exam of
the mouth
using a dental instrument (DE)

Nursing Intervention - No link to Medicaid

Abuse Protection Support: Child – identification of high-risk, dependent child relationships
and actions to
prevent possible or further infliction of physical, sexual, or emotional harm or neglect of
basic
necessities of life
Admission Care – facilitating entry of student into school (health needs)
Anticipatory Guidance (individual) – preparation of patient for an anticipated developmental
and/or
situational crisis
Anticipatory Guidance (group) – preparation of patient for an anticipated developmental
and/or
situational crisis
Body Mechanics Promotion (group) – facilitating the use of posture and movement in daily
activities to
prevent fatigue and musculoskeletal strain or injury
Environmental Management – manipulation of the patient’s surroundings for therapeutic
benefit
Health Education (group) – developing and providing instruction and learning experiences to
facilitate
voluntary adaptation of behavior conducive to health in individuals, families, groups, or
communities
Health System Guidance – facilitating a patient’s location and use of appropriate health
services
Infection Protection – prevention and early detection of infection in a patient at risk
Non-Nursing Intervention – providing service not requiring nursing skills and/or expertise
(not available

103

on current list)
Referral Arrangement - arrangement for services by another healthcare provider or agency
Self-Care Assistance, Non-Nursing – assisting another to perform activities of daily living (DE)
Seizure Precautions – prevention or minimization of potential injuries sustained by a patient
with a known
seizure disorder
Smoking Cessation Assistance (group) – helping another to stop smoking
Substance Use Prevention (group) – prevention of an alcoholic or drug use life-style
Suicide Prevention – reducing risk of self-inflicted harm with intent to end life
Surveillance: Safety – purposeful and ongoing collection and analysis of information about
the patient and
the environment for use in promoting and maintaining patient safety
Sustenance Support – helping a needy individual/family to locate food, clothing, or shelter

Section B - 21 - 6-2005
Approved Abbreviations and Symbols
A butt buttocks
a before
@ at C
abd abdomen c with
abdt abduction Ca carcinoma
abr abrasion cal calorie
a.c. before meals cap capsule
add adduction cath catheter
adeq adequate CBC complete blood count
ADL activities of daily living cc cubic centimeters
ad lib freely, as directed C.D. communicable disease
admin administration CHN Community Health Nurse
adv advise circ circulation
AFO ankle foot orthosis CMV cytomegalovirus
a.m. before noon, morning c/o complained of
amb ambulate COA children of alcoholics
amt amount comm communication
ans answer conf conference
ant anterior cont continued
AP apical pulse couns counselor
approx approximately C.P. cerebral palsy
appt appointment C.P.E. complete physical exam
AROM active range of motion CPR Cardiopulmonary resuscitation
ASAP as soon as possible C.R. classroom
ASHD anteriosclerotic heart disease CV cardiovascular
ASOM acute serous otitus media
asst assistance D
aud auditory DAT diet as tolerated
Ax temp axillary temperature d.c. discontinue
demo demonstrate
B D/I dry and intact
band Band-Aid diam diameter
B.C. pills birth control pills dig digoxin
104

BID twice daily dip distal interphalangeal
bilat bilateral disch discharge
BIW twice weekly discomf discomfort
BLE both lower extremities Dr. doctor
BM bowel movement drng drainage
BP blood pressure drsg dressing
BR bathroom dsd dry sterile dressing
brkfst breakfast DTP Diphtheria, Tetanus, Pertussis
BS breath sounds DTaP Diphtheria, Tetanus, acellular
Pertussis

B.T. bowel tones dx diagnosis
BUE both upper extremities dx’d diagnosed
Section B - 22 - 6-2005
E HC health card
ea each HCP health care provider
EEG electroencephalogram hct hematocrit
e.g. for example hgb hemoglobin
EI early intervention HL head lice
EKG electrocardiogram HOH hard of hearing
enc encourage hosp hospital
EPSDT Early and Periodic hr hour
Screening and Diagnostic HR health room
and Treatment Program h.s. at bedtime
equip equipment ht height
ER emergency room HTN hypertension
etiol etiology HV home visit
eval evaluation hx history
exer exercise
ext exterior I
ext rot external rotation IEP individualized educational
program
F IM intramuscular
FBS fasting blood sugar immed immediate
fe female immu immunization
FHX family history incl include
flex flexion incont incontinent
fr from indiv individual
freq frequency info information
FROM full range of motion inj injection
ft foot int internal
FU follow up int rot internal rotation
FWB full weight bearing intro introduction
fx fracture irreg irregular
irrig irrigation
G IV intravenous
gd good
105

G&D growth and development J-K
GI gastrointestinal jt joint
gm gram K+ potassium
gr grain Kg kilograms
gtts drops
GU genitourinary L
l liter
H lab laboratory
H20 water lang language
H202 hydrogen peroxide lat lateral
HA headache lb. pound
Section B - 23 - 6-2005
LB low back norm normal
LBP low back pain NPH type of insulin
LD learning disabled npo nothing by mouth
LE lower extremity NS normal saline
lg large nsg nursing
liq. liquid NTG nitroglycerin
LLCI lower left central incisor nutr nutrition
LLL left lower lobe N/V nausea and vomiting
LLQ left lower quadrant NWB non weight bearing
LMP last menstrual period
LOC level of consciousness O
LRCI lower right central incisor O none
LTG long term goal obj object
LUL left upper lobe obs observe
LUQ left upper quadrant occ occasionally
o.d. right eye
M OHI other health impaired
MD doctor OK okay
MDT multidisciplinary team OPC out-patient clinic
med medication OPV oral polio vaccine
mg milligram o.s. left eye
MI myocardial infarct OT occupational therapy
mid middle OTC over the counter
min minute o.u. both eyes
mm millimeter oz ounce
MMR Measles/Mumps/Rubella
vaccine P
mo month p after
MP menstrual period p pulse
MS multiple sclerosis par parent
musc muscle path pathology
MWB minimum weight bearing pc after meals
PC parent contact
N PE physical exam
106

Na+ sodium P.E. physical education
NANDA North American Nursing PERLA pupils equal and react to
Diagnosis light and accommodation
NaCI sodium chloride PMD private medical doctor
NAD no apparent distress po by mouth
NaHCO3 sodium bicarbonate P.O. post operative
NCP nursing care plan POMR problem oriented medical record
nec necessary pos positive
neg negative post posterior
noc at night PPBS post prandial blood sugar
Section B - 24 - 6-2005
PPD purified protein derivative RUL right upper lobe
PPP pedal pulses palpable RUOQ right upper outer quadrant
pres present RUQ right upper quadrant
princ principal Rx prescription
pm when necessary
prob problem S
prog prognosis s without
PROM passive range of motion satis satisfactory
PRO-TIME prothrombin time SBC school based clinic
pt patient sch school
PT physical therapy sched schedule, scheduled
P/U pick up, picked up scr screen, screening
PWB partial weight bearing SED seriously emotionally disturbed
sero-sang sero-sanguineous
Q shldr shoulder
q every sl slight
qd every day sm small
qh every hour SOAPIE Subjective, objective,
QID four times a day assessment (nursing diagnosis),
qmo every month plan, intervention, evaluation
qod every other day sob shortness of breath
qow every other week SOM serous otitis media
ques question sp speech
s/s signs and symptoms
R S/T sore throat
RA rheumatoid arthritis stat at once
rec recommend subq subcutaneous
ref refer, referred, referral superf superficial
reg regular supp suppository
req request SV school visit
resp respiration SW social worker
RLL right lower lobe Sx symptoms
RLQ right lower quadrant
RN Registered Nurse T
R/O rule out tab tablet
107

ROM range of motion TBI traumatic brain injury
rpt repeat, repeats, repeated tbsp tablespoon (15cc.)
R&R rate and rhythm tc telephone call
RR respiratory rate temp temperature
RSW right side weakness tet.tox. tetanus toxoid
R/T related to TID three time a day
RTC return to class TM tympanic membrane
rtn return TMR trainable mentally retarded
RTO return to office TOPV trivalent oral polio vaccine
Section B - 25 - 6-2005
TPR temperature, pulse, respiration
tr trace
trach tracheostomy
transc transcribe, transcribed
tsp teaspoon (5 cc.)
tx treatment
U
UA urinalysis
U.A.P. unlicensed assistive personnel
U.I. unit of insulin
ULCI upper left central incisor
URCI upper right central incisor
URI upper respiratory infection
UTC unable to contact
UTI urinary tract infection
V
VA Veterans Administration
vag vaginal
vasc vascularity
vis visual
vocab vocabulary
VS vital signs
W
WBC white blood count
wc wheelchair
w&d warm & dry
W/D withdraw, withdrawn
wk week
wnd wound
WNL within normal limits
wt weight
X-Y-Z
y.o. year old
1996, Hootman, J. Quality Nursing Interventions in the School Setting:
Procedures,
Model, and Guidelines. NASN. Used with permission.
108

Section B - 26 - 6-2005
L

APPROVED ABBREVIATIONS AND SYMBOLS
_ Approximately
R Change
S Check
_ Decrease
= Equals
U Female
> Greater than
_ Increase
_ Leading or progressing to
< Less than
X Male
- Minus
# Number
1x One time
O2 Oxygen
¶ Paragraph
/ Per
% Percent
+ Plus
? Questions
_ Unstable
Ø Zero, none
® Right
L Left
Section B - 27 - 6-2005
STUDENT ACCIDENT REPORT FORM
This form, or a similar one preferred by the district, is to be completed on each injury which
occurs in the
school building, on the school grounds, while the student is on his/her way to or from school
activities that
result in one-half or more day’s absence from school or requires a doctor’s attention or both.
Submit all
completed reports to the designated office in school district. It is recommended that a
duplicate copy of this
report be prepared for the school’s file.
1. NAME AGE SEX: M F
2. DISTRICT SCHOOL GRADE OR CLASSIFICATION
3. TIME Accident Occurred: Hour a.m. or p.m. Date DATE Accident Reported
4. NATURE OF ACCIDENT. Check all appropriate areas. (To be completed by nurse or other designated
personnel.)

Nature of Injury Part of Body Injured
(Indicate L or R for left or right when applicable)

Abrasion Dental Ankle Face Knee Shoulder
Bite Dislocation Arm Finger Leg Stomach
Bruise Foreign body in eye Back Foot Lip Tooth
Burn Laceration Chest Hand Mouth Wrist
Chemical Burn Puncture Collar Bone Head Neck Other

109

Concussion Sprain/Strain Elbow Hip Nose
Cut Other (specify) Eye Scalp

5. Subjective Data
Objective Data
Date of last tetanus shot
Assessment
Intervention
CONTINUE TO NEXT PAGE

Section B - 28 - 6-2005
STUDENT ACCIDENT REPORT FORM - continued
6. How did accident happen? What was student doing? Where was student? List specifically
any unsafe
act(s) and/or unsafe condition(s). Specify any tool, machine or equipment involved.
7. What action(s) was taken and by whom?
First aid treatment By whom? (Enter name)
Sent to school nurse By whom? (Enter name)
Sent home By whom? (Enter name)
Sent to physician By whom? (Enter name)
Sent to hospital By whom? (Enter name)

8. Was parent/guardian or anyone notified? Yes No
When: Date Time How
9. Please complete below:
Location Activities Area
Athletic Field Apparatus Building
Auditorium Ball Playing Grounds
Cafeteria Baseball Interscholastic
Classroom Basketball Intramural
Corridor Field Hockey Physical Education
Dressing Room Football Shops
Gymnasium Free Play Labs
Home Economics Gymnastics
Laboratories Running To and From School
Lockers Soccer Bicycle
School Grounds Softball Motor Veh Passenger
School Shops Swimming Motor Veh Bicycle
Science Track and Field Motor Veh Pedes.
Showers/Dressing Room Volleyball School Bus
Stairs Inside Wrestling Streets and Walks
Stairs and Walks Outside Other Other
Toilet Rooms
Voc and Indus. Arts

10. Total number of school days lost (To be recorded when student returns to school)
11. Student is covered by Student Accident Insurance Yes No
12. Person in charge when accident occurred (Signature)
Nurse Principal

Section B - 29 - 7-2007
DEPARTMENT OF EDUCATION
DISTRICT/CHARTER SUMMARY OF SCHOOL HEALTH SERVICES
July 1, 20__ through June 30, 20__
Due Date: 8/31/_____ Return to : Linda C. Wolfe, RN, Health Services
Justification: The State Board shall prescribe rules and regulations governing the protection of health, physical
welfare and physical inspection of public school children in the State. 14
Del Code 122(b)(2)
School or School District: ________________________________________________
I. Clients Students Staff Visitors Total % Total Stud
Population
% Total Staff
Population
A. Unduplicated Clients receiving Health Services

110

B. Nurse Office Visits (minutes out of class)
1. < 15 min.
2. 16 - 30 min.
3. 31 - 45 min.
4. 46 - 60min.
5. 61 - 120 min.
6.> 120 min.
7. Average time
8. Total Visits (B1 - B6)
C. Disposition: % after nurse intervention
1. Returned to class/activity
2. Sent to school staff (ex. principal, counselor)
3. Sent to Wellness Center
4. Sent home
5. Exclusion for communicable disease
6. Sent for immediate evaluation/treatment
7. 911
8. Other
D. Contacts/Communication/Notification re: client
1. Parents/Guardian
2. School
3. Community
II. Nursing Care: Assessment & Intervention Students Staff Visitors Total Outcome (Resolution/
Improvement)
A. Functional: Care to promote basic health needs
1. Activity/Exercise n/a FY07
2. Comfort/Rest n/a FY07
3. Growth & Development/Nutrition n/a FY07
4. Self-Care n/a FY07
B. Physiological: Care to promote optimal biophysical
health
1. Physical Health & Well-Being
a. Special Nursing Procedures n/a FY07
b. First Aid/ Emergency Care n/a FY07
c. Body Systems Support (ex. cardiac, resp., tissue) n/a FY07
2. Pharmacological n/a FY07
a. Medications
b. Treatments
c. Unduplicated Students receiving Rx/Tx

Section B - 30 - 7-2007

C. Psychosocial: Care to promote optimal emotional health
and social functioning
1. Coping/Emotional Support n/a FY07
2. Communication/Relationships n/a FY07
3. Knowledge n/a FY07
4. Behavior/Self-perception n/a FY07
D. Environment: Care to protect and promote health and
safety
1. Health Care System n/a FY07
2. Risk Management n/a FY07
3. Individual Emergency Plan
4. Individualized Healthcare Plan
5. IEP/504 Plan
E. Nursing Assessments/Interventions unclassified
F. Non-Nursing Interventions
G. TOTAL Interventions
Total Referred Completed
Referral
% Completed
H. Office Visits
III. Health Screening Total
Screened
Referred Completed
Referral
% Completed Number Required % Required
Receiving
Screening
A. Required (Students)

111

1. Hearing
2. Immunization
3. Postural/Gait
4. Physical report
5. TB Questionnaire/Reading
6. Vision
7. Total Number of Required Screenings
B. Non-Required (Students)
1. Blood Pressure
2. BMI
3. Dental
4. Developmental
5. Pediculosis
6. Record Review
7. Other
8. Total Number of Non-Required Screenings
C. Total Student Screenings
D. Staff
1. BP
2. TB Questionnaire/Reading
3. Other
4. Total Number
E. Total Screenings (III. C + III. D.4)
Date: _______________________ Signature _________________________________

Section B - 31 - 7-2007

PAGE DELETED
Section B - 32 - 6-2005

INTERAGENCY CONSENT TO RELEASE INFORMATION
Sharing information helps agencies provide better services to me/my child and/or my family. Only
those agencies listed below
that are planning or giving services to me or my child may receive information.
When relevant, shared information will include:
* my/child’s full name * telephone number * address
* social security number * birthdate * names of parents/brothers/sisters/spouse
* items specified below
I understand that this form is not used to release information about drug and alcohol treatment.
I, , also allow all of the listed agencies to share the following information
about my child/me, (birthdate ).
Please specify: INFORMATION THAT MAY BE SHARED
Please specify: AGENCIES THAT MAY SEND/RECEIVE INFORMATION
(Include Originating Agency Name)

Section B - 33 - 6-2005
AGREEMENT TO RELEASE
This permission is good for one year after I sign it.
I agree to the interagency sharing of information. I can take away my permission at any time. I can
also change it at any time
unless the information has already been released.
Print Name:
Signature:
Date:
Please check all that apply:
Parent [ ] Guardian [ ] Legal Adult (18 years) [ ] Minor 12-18, required below *[ ] Custodian [ ]
*A minor must specifically consent to the release of HIV [ ], STD [ ], and pregnancy information [ ].
Signature of minor: Date
ORGANIZATION’S AFFIRMATION
As the participating organization’s representative, I affirm that I have reviewed this form and its use
with the consenting person
and that to the best of my knowledge he/she understands.
Witness Date
Agency
TRANSLATOR’S STATEMENT

112

I have orally translated/read/signed the above into (language). To the best of my knowledge, I believe
the consenting person understands the nature and use of this form.
Translator’s Signature Date
……………………………………..
Revocation Statement
I, (consenting person), take away the consent I gave to
(originating organization) on (date). I understand
that (originating organization) will notify any participating organization to
which information has been sent or from which information has been received.
Signature Date
Witness Date
Agency Revocation letter attached (Yes/No)
_ The Interagency Consent to Release Information Form is based on the Interagency Confidentiality
Agreement for
Accessibility in Data Sharing between Participating Organizations: Department of Health & Social
Services (DHSS),
Department of Services for Children, Youth and their Families (DSCYF), Department of Education (DOE),
Department of
Correction (DOC), Department of Labor (DOL) and local school districts. This document has been
approved by the
Attorney General’s Office. This form may not be altered in any manner without written authorization
from the State of
Delaware Interagency Confidentiality Committee. This form may be photocopied for use by the
participating organizations.
The State of Delaware does not discriminate or deny services on the basis of race, religion, color,
national origin, sex, disability
and/or age.

Section B - 34 - 6-2005

III. School Entry
Section B - 35 - 4-2008
804 Immunizations
1.0 Definition
"School Enterer" means any child between birth and twenty (20) years inclusive entering or being
admitted to a Delaware school
district for the first time, including but not limited to, foreign exchange students, immigrants, students
from other states and territories
and children entering from nonpublic schools.
2.0 Minimum Immunizations Required for All School Enterers
2.1 All School Enterers shall have immunizations given up to four days prior to the minimum interval or
age and shall include:
2.1.1 Four or more doses of diphtheria, tetanus, pertussis (DTaP, DTP, or other approved vaccine) or a
combination of these five
vaccines. A booster dose of Td or Tdap (adult) is recommended by the Division of Public Health for all
students at age 11 or
years after the last DTaP, DTP or DT dose was administered whichever is later. Notwithstanding this
requirement:
2.1.1.1 A child who received a fourth dose prior to his or her fourth birthday shall have a fifth dose;
2.1.1.2 A child who received the first dose of Td (adult) at or after age seven may meet this
requirement with only three
doses of Td or Tdap (adult).
2.1.2 Three or more doses of inactivated polio virus (IPV), oral polio vaccine (OPV), or a combination of
these vaccines with
the following exception: a child who received a third dose prior to the fourth birthday shall have a
fourth dose.
2.1.3 Two doses of measles, mumps and rubella (MMR) vaccine. The first dose should be administered
on or after the age of 12
months. The second dose should be administered after the fourth birthday. Individual combination
vaccines of measles, mumps,
rubella (MMR) may be used to meet this requirement.

113

2.1.3.1 Disease histories for measles, rubella and mumps shall not be accepted unless serologically
confirmed.
2.1.4 Three doses of Hepatitis B vaccine.
2.1.4.1 For children 11 to 15 years old age, two doses of a vaccine approved by the Center for Disease
Control (CDC) may be
used.
2.1.4.2 Titers are not acceptable in lieu of completing the vaccine series and a disease history for
Hepatitis B shall not be
accepted unless serologically confirmed.
2.1.5 Varicella vaccine is required beginning in the 2003-2004 school year with kindergarten. One
grade shall be added each year
thereafter so that by the 2015-2016 school year all children in grades kindergarten through 12 shall
have received the vaccination.
Beginning in the 2008-2009 school year new enterers into the affected grades shall be required to
have two doses of the
Varicella vaccine. The first dose shall be administered on or after the age of twelve (12) months and
the second at kindergarten
entry into a Delaware public school. A written disease history, provided by the health care provider,
parent, legal guardian,
Relative Caregiver or School Enterer who has reached the statutory age of majority (18), 14 Del.C.
§131(a)(9), will be accepted
in lieu of the Varicella vaccination. Beginning in the 2008-2009 school year, a disease history for the
Varicella vaccination must
be verified by a health care provider to be exempted from the vaccination.
2.2 Children who enter school prior to age four (4) shall follow current Delaware Division of Public
Health recommendations.
3.0 Certification of Immunization
3.1 The parent, legal guardian, Relative Caregiver or a School Enterer who has reached the statutory
age of majority (18), 14 Del.C.
§131(a)(9), shall present a certificate specifying the month, day, and year that the immunizations were
administered by a licensed
health care practitioner.
3.2 According to 14 Del.C. §131, a principal or person in charge of a school shall not permit a child to
enter into school without
acceptable evidence of immunization. The parent, legal guardian, Relative Caregiver or a School
Enterer who has reached the
statutory age of majority (18), 14 Del.C. §131(a)(9), shall be notified of this requirement in writing.
Within 14 calendar days after
notification, evidence must be presented to the school that the basic series of immunizations has been
initiated or has been completed.
3.3 A school enterer may be conditionally admitted to a Delaware school district by presenting a
statement from a licensed
health care practitioner who specifies that the School Enterer has received at least:
3.3.1 One dose of DTaP, or DTP, or DT; and
3.3.2 One dose of IPV or OPV; and
3.3.3 One dose of measles, mumps and rubella (MMR) vaccine; and
3.3.4 The first dose of the Hepatitis B series; and
3.3.5 One dose of Varicella vaccine as per 2.5.
3.4 14 DE Admin. Code 901 Education of Homeless Children and Youth 6.0 states that "School districts
shall ensure that policies
concerning immunization, guardianship and birth certificates do not create barriers of the school
enrollment of homeless children and
youth". To that end, school districts shall as stated in 14 DE Admin. Code "assist homeless children and
youth in meeting the
immunization requirements".
3.5 If the school enterer fails to complete the series of required immunizations the parent, legal
guardian, Relative Caregiver or a school
enterer who has reached the statutory age of majority (18), 14 Del.C. §131(a)(9), shall be notified that
the School Enterer will be
excluded according to 14 Del.C. §131.
4.0 Lost or Destroyed Immunization Record

114

When a student’s immunization record has been lost or destroyed by the medical provider who
administered the vaccine, the parent, legal
guardian, Relative Caregiver or a school enterer who has reached the statutory age of majority (18), 14
Del.C. §131(a)(9),shall sign a
written statement to this effect and must obtain at least one dose of each of the immunizations as
identified in 3.3. Evidence that the
vaccines were administered shall be presented to the superintendent or his or her designee.
5.0 Exemption from Immunization
5.1 Exemption from this requirement may be granted in accordance with 14 Del.C. §131 which permits
approved medical and notarized
religious exemptions.
5.2 Alternative dosages or immunization schedules may be accepted with the written approval of the
Delaware Division of Public Health.

Section B - 36 - 4-2008
6.0 Verification of School Records
The Delaware Division of Public Health shall have the right to audit and verify school immunization
records to determine compliance with
the law.
7.0 Documentation
7.1 School nurses shall record and maintain documentation of each student's immunization status.
7.2 Each student's immunization record shall be included in the Delaware Immunization Registry.

Approved Immunization Alternative Doses and/or Schedules

5.2 Alternative dosages or immunization schedules may be accepted with the
written approval
of the Division of Public Health.
The following have been reviewed by the Division of Public Health:
1. Titers in lieu of completion of the Hep B series are not acceptable (12/1/00).
2. In lieu of two MMRs, the child can receive two measles, one ubella and one
mumps
(5/19/04).
3. A second MMR given prior to the fourth birthday is accepted, although not
recommended as
standard protocol, if:
• the first dose was not earlier than the first birthday and
• there is a minimal 28-day interval between doses (5/19/04).
4. If a child receives one dose of Varicella and later develops the disease, a second
dose is not
required. A verified disease history is required. (12/28/07)
5. DPH follows the CDC “catch-up” schedule for students who are behind in
vaccinations.
(1/22/08)
6. An exemption from the Varicella requirement is allowed based upon a physician’s
note
reporting a protective level based upon a Varicella Zoster IgG. (2/19/08)

Section B - 37 - 4-2008
•SAMPLELETTER

(Regarding School Entry)
Dear Parent/Guardian:
According to Delaware laws and Department of Education regulations, all
children
entering school for the first time are required to have proof on file of the
following:
115

Immunizations1
5 or more doses of DTaP, DTP or TD vaccine (unless 4th dose was
given after the 4th birthday)
4 doses of IPV or OPV (unless the 3rd dose was given after the 4th
birthday)
2 doses of measles, mumps and rubella vaccine (first dose after the
age of 12 months, second dose after the 4th birthday)
3 doses of Hepatitis B vaccine
2 doses of Varicella or a written disease history by a licensed
healthcare provider (08/09 School Year: New enterers to
Grades K-5; 09/10 School Year: New enterers to Grades K-6;
10/11 School Year: New enterers to Grades K-7, etc.)
Physical2
Current, within the two years prior to entry into school
Tuberculosis3
Results of Mantoux screening completed within the past 12
months or risk assessment as recommended by Delaware
Division of Public Health
Lead blood test4
Documentation for children entering kindergarten or pre-school
program
Please provide the school nurse with the necessary information. We
appreciate your
cooperation in complying with the law.
Sincerely,
(Superintendent or Principal)
Delaware Code, Title 14, Section 131
Department of Education Regulation 804
3 Department of Education Regulation 805
4 Delaware Code, Title 16, Chapter 26
1
2

Section B - 38 - 4/2008

SAMPLE
(School/School District Name)
VARICELLA (Chickenpox) IMMUNITY STATEMENT
Name: Birthdate:
Please Print
Check one of the following boxes regarding Varicella (Chickenpox) Immunity:
_ Varicella Vaccine Date Given:
_ Varicella Lab Evidence Date:
_ Varicella Disease Age of child when he/she had Chickenpox:
Name:
Licensed healthcare provider
Signature: Date:

Section B - 39 - 6/2005
AFFIDAVIT REQUIRED PER 14 DEL. CODE SEC. 131
AFFIDAVIT OF RELIGIOUS BELIEF
STATE OF DELAWARE
116

………. COUNTY
1. (I) (We) (am) (are) the (parent[s]) (legal guardian[s]) of ………………………..
Name of Child
2. (I) (We) hereby (swear) (affirm) that (I) (we) subscribe to a belief in a
relation to a
Supreme Being involving duties superior to those arising from any human
relation.
3. (I) (We) further (swear) (affirm) that our belief is sincere and meaningful
and occupies a
place in (my) (our) life parallel to that filled by the orthodox belief in God.
4. This belief is not a political, sociological or philosophical view of a merely
personal
moral code.
5. This belief causes (me) (us) to request an exemption from the mandatory
school
vaccination program for .
Name of Child
Signature of Parent(s) or Legal Guardian(s)
SWORN TO AND SUBSCRIBED before me, a registered Notary Public, this
day of , 2 .
(Seal)
Notary Public
My commission expires:
Section B - 40 - 6/2005
Instructions for Completing School Immunization Records

1. If a computer is not used for immunization records, initiate a School Immunization
Record
form on each new enterer in Grades K-12 even if no immunization information is
available.
If a computer is used, print a copy and mail to Immunization Program.
2. Print legibly with a ballpoint pen and bear down.
3. Enter the appropriate “School Information” and “Student Information.”
4. Enter the dates of documented immunizations in the area entitled
“Immunizations.”
5. Retain one copy of the Immunization Record for pupil’s record folder. Mail one
copy to
Immunization Program.
6. Obtain additional forms from your District Coordinator, District School Nurse
Liaison or
Immunization Program (1-800-282-8672).
7. Access Delaware’s Immunization Registry at http://vacattack.dhss.delaware.gov.
Delaware Division of Public Health
School Immunization Record
Mail To: Immunization Program, HMPC
Jesse Cooper Bldg. D320A, Dover DE 19901
1. School Information
School Code:
School:
2. Student Information
Date of Birth:

117

Student Name:
Sex: _Male _Female Last First Mi
Race: _Alaskan Native Student Address:
_AmericanIndian
_African American
_Caucasian
Address
_Hispanic
_Pacific Island/Asian
_Unknown _Other
City State Zip
3. Immunizations – Shaded Vaccines Required
DTP/Hib 1
//
DTP/Hib 2
//
DTP/Hib 3
//
DTP/ Hib 4
//
DTaP/Hib 4
//
DTP/DTaP 1
//
DTP/DTaP 2
//
DTP/DTaP 3
//
DTP/DTaP 4
//
DTP/DTaP 5
//
DT/Td 1
//
DT/Td 2
//
DT/Td 3
//
DT/Td 4
//
DT/Td 5
//
OPV/IPV 1
//
OPV/IPV 2
//
OPV/IPV 3
//
OPV/IPV 4
//
OPV/IPV 5
//
MMR 1
//
MMR 2
//
HepB 1
//
HepB 2
//
HepB 3
//
Hib 1
//
Hib 2
//
Hib 3
//
Hib 4

118

//
Hep B 1 (2 dose
Version Only)
//
Hep B 2 (2 dose
Version Only)
//
Hep B/Hib 1
//
Hep B/Hib 2
//
Hep B/Hib 3
//
Varicella 1
//
Varicella 2
//
Lyme Vax 1
//
Lyme Vax 2
//
Lyme Vax 3
//
Pneumococcal
Conjugate 1
//
Pneumococcal
Conjugate 2
//
Pneumococcal
Conjugate 3
//
Pneumococcal
Conjugate 4
//
Pneumococcal
Polysaccharide1
//
Pneumococcal
Polysaccharide 2
//
Hep A 1
//
Hep A 2
//
Influenza 1
//
Influenza 2
//
Other:
//
Other:
//
CH- 125 New 12/00
DOC. # 35-05-20/00/12/06

Section B - 41 - 7-2007
CDC RECOMMENDED CHILDHOOD AND ADOLESCENT IMMUNIZATION SCHEDULE
Taken from: www.cdc.gov

Section B - 42 - 7-2007

805 The School Health Tuberculosis (TB) Control Program
1.0 Definitions:
“New School Enterer” means any child between the ages of one year and twenty one (21)
years entering or
being admitted to a Delaware public school for the first time, including but not limited to,
foreign exchange

119

students, immigrants, students from other states and territories, and children entering from
nonpublic
schools. For purposes of this regulation, “new school enterer” shall also include any child
who is reenrolled
in a Delaware public school following travel or residency of one month in a location or facility
identified by the Delaware Division of Public Health as an area at risk for TB exposure.
“School Staff and Extended Services Personnel” means all persons hired as full or part time
employees in a
public school who are receiving compensation to work directly with students and staff. This
includes, but is
not limited to teachers, administrators, substitutes, contract employees, bus drivers and
student teachers
whether compensated or not.
“Tuberculosis Risk Assessment” means a formal assessment by a healthcare professional to
determine
possible tuberculosis exposure through the use of a health history or questionnaire.
“Verification” means a documented evaluation of the individual’s disease status.
“Volunteers” mean those persons who give their time to help others for no monetary reward
and who share
the same air space with public school students and staff on a regularly scheduled basis.
2.0 School Staff and Extended Services Personnel
2.1 School staff and extended services personnel shall provide the Mantoux tuberculin skin
test results
from a test administered within the past 12 months during the first 15 working days of
employment.
2.1.1 Tuberculin skin test requirements may be waived for public school staff and extended
services personnel who present a notarized statement that tuberculin skin testing is against
their religious beliefs. In such cases, the individual shall complete the Delaware
Department of Education TB Health Questionnaire for School Employees or provide,
within two (2) weeks, verification from a licensed health care provider or the Division of
Public Health that the individual does not pose a threat of transmitting tuberculosis to
students or other staff.
2.1.1.1 If a school staff member or extended services person, who has received a
waiver because of religious beliefs, answers affirmatively to any of the
questions in the Delaware Department of Education TB Health Questionnaire
for School Employees he/she shall provide, within two (2) weeks, verification
from a licensed health care provider or the Division of Public Health that the
individual does not pose a threat of transmitting tuberculosis to students or
other staff.
2.1.2 Student teachers need not be retested if they move from district to district as part of
their
student teaching assignments.
2.2 Every fifth year, by October 15th, all public school staff and extended services personnel
shall
complete the Delaware Department of Education TB Health Questionnaire for School
Employees
or, within two (2) weeks, provide Mantoux tuberculin skin test results administered within
the last
twelve (12) months.
2.2.1 If a school staff member or extended services staff member answers affirmatively to
any
of the questions in the Delaware Department of Education TB Health Questionnaire for
School Employees he/she shall provide, within two (2) weeks, verification from a licensed
health care provider or the Division of Public Health that the individual does not pose a
threat of transmitting tuberculosis to students or other staff.

120

2.3 All documentation related to the School Health Tuberculosis (TB) Control Program shall
be
retained in the same manner as other confidential personnel medical information.
3.0 Volunteers
3.1 Volunteers shall complete the Delaware Department of Education’s TB Health
Questionnaire for
Volunteers in Public Schools prior to their assignment and every fifth year thereafter.
3.1.1 If the volunteer answers affirmatively to any of the questions, he/she shall provide,
within
two (2) weeks, verification from a licensed health care provider or the Division of Public
Health that the individual does not pose a threat of transmitting tuberculosis to the

Section B - 43 - 7-2007
students or staff.
3.2 Each public school nurse shall collect and monitor all documentation related to the
School Health
Tuberculosis (TB) Control Program and store them in the school nurse’s office in a
confidential
manner.
4.0 New School Enterers
4.1 New school enterers shall show proof of tuberculin screening results as described in
4.1.1 and 4.1.2
including either results from the Mantoux Tuberculin test or the results of a tuberculosis risk
assessment. Multi-puncture skin tests will not be accepted.
4.1.1 If the new school enterer is in compliance with the other school entry health
requirements,
a school nurse who is trained in the use of the Delaware Department of Education TB Risk
Assessment Questionnaire for Students may administer the questionnaire to the student’s
parent(s), guardian(s) or Relative Caregiver or to a new school enterer who has reached
the statutory age of majority (18).
4.1.1.1 If a student’s parent(s), guardian(s) or Relative Caregiver or a student 18 years
or older answers affirmatively to any of the questions, he/she shall, within two
(2) weeks, provide proof of Mantoux tuberculin skin test results or provide
verification from a licensed health care provider or the Division of Public
Health that the student does not pose a threat of transmitting tuberculosis to
staff or other students.
4.2 School nurses shall record and maintain documentation relative to the School Health
Tuberculosis
(TB) Control Program.
5.0 Tuberculosis Status Verification and Follow-up
5.1 Tuberculosis Status shall be determined through the use of a tuberculosis risk
assessment,
tuberculin skin test and other testing, which may include x-ray or sputum culture. Individuals
who
either refuse the tuberculin skin test or have positive reactions to the same, or give positive
responses to a tuberculosis risk assessment shall provide verification from a licensed health
care
provider or the Division of Public Health that the individual does not pose a threat of
transmitting
tuberculosis to staff or other students.
5.1.1 Verification shall include Mantoux results recorded in millimeters (if test were
administered), current disease status (i.e. contagious or non-contagious), current treatment
(or completion of preventative treatment for TB) and date when the individual may return
to his/her school assignment without posing a risk to the school setting.
5.1.2 Verification from a health care provider or Division of Public Health shall be required
only once if treatment was completed successfully.

121

5.1.3 Updated information regarding disease status and treatment shall be provided to the
public
school by October 15 every fifth year if treatment was previously contraindicated,
incomplete or unknown.
5.2 In the event an individual shows any signs or symptoms of active TB infection, he/she
must be
excluded from school until all required medical verification is received by the school.

Section B - 44 - 6-2005
Employee Name: Date:
Employee Signature:

Delaware Department of Education1
CONFIDENTIAL TB Health Questionnaire for School Employees
The Delaware Department of Education Regulation 805 2 requires all school
employees to provide
Mantoux tuberculosis (TB) skin test results during the first 15 days of employment.
Every 5th year, by
October 15, all3 personnel shall complete the TB Health Questionnaire for School
Employees as a routine
follow-up screening. This document shall be retained in the same manner as other
confidential personnel
medical information.

Please consider the following questions and indicate one response in the box
below:
1. In the past five years, have you lived or been in close contact with anyone who
had TB disease?
2. Do you currently have any of the following symptoms which are unexplained and
which have lasted
at least three weeks?
Cough
Fever
Night sweats
Weight loss
3. Have you ever had a positive HIV test?
4. In the past five years, have you ever used illegal intravenous drugs?
5. In the past five years, have you been incarcerated?
6. In the past five years, have you been homeless?
7. Consider the list of countries/continents below:
• Africa
• Asia
• Eastern Europe
• Caribbean
• Latin America
• Pacific Islands
In the past five years, have you stayed/lived in one of these countries for 1 month
or longer?
In the past five years, have you lived or been in close contact with someone who
stayed/lived in one
of these countries for 1 month or longer?

Can you answer “yes” to any of the above questions? ( ) Yes ( ) No
122

If you checked YES, you are required (within 2 weeks) to provide verification from a
licensed health care
provider or the Division of Public Health that there is no communicable threat.
If you have any questions about your risk of infection, please speak with your
healthcare provider or
contact the Delaware Division of Public Health TB Elimination Program at 302-7412923.
Developed in collaboration with the Division of Public Health, 2/05.
Regulation 805 can be accessed at http://www.state.de.us/research/AdminCode/title14/800
3 Anyone with a previous positive Mantoux shall provide updated information regarding
disease status and treatment
to the public school by October 15 every fifth year if treatment was previously
contraindicated, incomplete or
unknown.
1
2

Section B - 45 - 6-2005
Delaware Department of Education1
Student TB Risk Assessment Questionnaire
Prior to use of this form, the school nurse must review the student’s health records
and assure that the
student is compliant with the requirement for a current physical (within past 2
years) and up-to-date
immunizations. The questionnaire must be administered by the school nurse to the
parent/guardian in
person or by phone and signed by the parent who answered the questions.
Name:
Last First MI
Date of Birth: ____/_____/____ Date Form Completed ___/___/___
1. Has your child had any contact with a case of TB?
2. Was any household member, including your child, born in or has he/she traveled
to areas where TB is
common (i.e., Africa, Asia, Latin America, and the Caribbean)?
3. Does your child have regular (i.e., daily) contact with adults at high risk for TB
(i.e., those who are
HIV infected, homeless, incarcerated, and/or illicit drug users)?
4. Does your child have any health conditions or take medications that might affect
his/her immune
system?
Any “yes” response is considered a positive risk factor and is an indication for
administering a Mantoux
tuberculin skin test to the child.
This child has been screened by his/her school nurse for risk of exposure to
tuberculosis. Based upon the
results of the TB Risk Assessment Questionnaire the child,
____does not require a Mantoux skin test
____does require a Mantoux skin test
Mantoux testing and documentation is required to be completed and given to the
school nurse by
____/_____/____ (date) or your child will be excluded from school.
School Nurse comments:
School Nurse (signature)
123

I give permission for the school nurse and my child’s primary care physician
____________________________ (name of physician) to share information relating to
this form.
Parent/Guardian (signature)
Student questionnaire was developed in collaboration with the Division of Public Health,
8/04. Regulation 805,
The School Health Tuberculosis (TB) Control Program, can be accessed at
http://www.state.de.us/research/AdminCode/title14/800
1

Section B - 46 - 6-2005
Name Date

DELAWARE DEPARTMENT OF EDUCATION
CONFIDENTIAL HEALTH QUESTIONNAIRE FOR VOLUNTEERS

All school employees are required to have a tuberculosis (TB) skin test. The purpose
of this requirement
is to safeguard school-aged children from exposure to TB in the school setting. In
the same way, this
questionnaire is designed to identify volunteers who MAY have been exposed to TB
and thus need further
screening. A school designee will collect and monitor the Health Questionnaire,
which will be stored in
the School Nurse’s office in a confidential manner.

Please consider the following questions:

1. Have you ever lived or been in close contact with anyone who had TB disease?
2. Have you ever had a positive HIV test?
3. Have you ever used illegal intravenous drugs?
4. Have you ever been incarcerated?
5. Have you ever been homeless?
6. Do you currently have any of the following symptoms which are unexplained and
which have lasted
at least three weeks?
Cough
Fever
Night sweats
Weight loss
7. Consider the list of countries/continents below:
• Africa
• Asia, including China, Vietnam, Korea, Indonesia, India, Pakistan, Bangladesh
• Eastern Europe, including Russia and former Soviet Union, Armenia
• Haiti
• Latin America, including Mexico, Guatemala, and South America
• Pacific Islands, including Philippines
Were you born in one of these countries?
Have you ever stayed/lived in one of these countries for 1 month or longer?
Have you ever lived or been in close contact with someone who stayed/lived in one
of these countries
for 1 month or longer?
Can you answer “yes” to any of the above questions? ( ) Yes ( ) No
If you checked yes, you are required to have a Mantoux test prior to your
assignment as a
volunteer.
124

Have you ever had a positive skin test for tuberculosis? ( ) Yes ( ) No
If you checked yes, you are required to provide documentation related to current
disease status
prior to your assignment as a volunteer.
These requirements are for the safety of our school and for your personal health.
Screening for
tuberculosis is recommended by health professionals for any individual who is at
risk. Routine screening,
using a Mantoux tuberculin skin test, can detect if a person has been exposed to
tuberculosis. Such early
identification is of great benefit in reducing the effects of disease.
If you have any questions about your risk of infection, please speak with your
healthcare provider or plan
to discuss it at your next examination. For additional information, you can contact
the Delaware Division
of Public Health TB Elimination Program at 302-739-6620.

Section B - 47 - 6-2005
Affidavit of Religious Belief
STATE OF DELAWARE
COUNTY
1. (I) (We) (am) (are) the (parent[s]) (legal guardian[s]) (Relative
Caregiver[s]) of
Name of Child
1. (I) (We) hereby (swear) (affirm) that (I) (we) subscribe to a belief in a
relation to a
Supreme Being involving duties superior to those arising from any human
relation.
2. (I) (We) further (swear) (affirm) that our belief is sincere and meaningful
and occupies a
place in (my) (our) life parallel to that filled by the orthodox belief in God.
3. This belief is not a political, sociological or philosophical view of a merely
personal moral
code.
4. This belief causes (me) (us) to request an exemption from the mandatory
Mantoux
tuberculin skin test for .
Name of Child
Signature of Parent(s) or Guardian(s)
SWORN TO AND SUSCRIBED before me, a registered Notary Public, this
day of , 20____.
(Seal)
Notary Public
My commission expires:
Section B - 48 - 7-2007
815 Physical Examinations and Screening

1.0 Physical Examinations
1.1 All public school students shall have a physical examination that has been administered
by a

125

licensed medical physician, nurse practitioner or physician's assistant. The physical
examination
shall have been done within the two years prior to entry into school. Within fourteen
calendar days
after notification of the requirement for a physical examination, new enterers shall have
received a
physical examination or shall have a documented appointment with a licensed health care
provider
for a physical examination.
1.1.1 The requirement for the physical examination may be waived for students whose
parent,
guardian or Relative Caregiver, or the student if 18 years or older, or an unaccompanied
homeless youth (as defined by 42 USC 11434a) presents a written declaration acknowledged
before a notary public, that because of individual religious beliefs, they reject the concept of
physical examinations.
1.1.2 The school nurse shall record all findings on the Delaware School Health Record Form
(see
14 DE Admin. Code 811) and maintain the original copy in the child’s medical file.
NON REGULATORY NOTE: See 14 DE Admin. Code 1008.3 and 14 DE Admin. Code 1009.3 for
physical examination requirements associated with participation in sports.
2.0 Screening
2.1 Vision and Hearing Screening
2.1.1 Each public school student in kindergarten and in grades 2, 4, 7 and grades 9 or 10
shall receive a
vision and a hearing screening by January 15th of each school year.
2.1.1.1 In addition to the screening requirements in 2.1.1, screening shall also be provided to
new
enterers, students referred by a teacher or an administrator, and students considered for
special education.
2.1.1.1.1 Driver education students shall have a vision screening within a year prior to their
in car driving hours.
2.1.2 The school nurse shall record the results on the Delaware School Health Record Form
and shall
notify the parent, guardian or Relative Caregiver or the student if 18 years or older, or an
unaccompanied homeless youth (as defined by 42 USC 11434a) if the student has a
suspected
problem.
2.2 Postural and Gait Screening
2.2.1 Each public school student in grades 5 through 9 shall receive a postural and gait
screening by
December 15th.
2.2.2 The school nurse shall record the findings on the Delaware School Health Record Form
(see 14 DE
Admin. Code 811) and shall notify the parents, guardian or Relative Caregiver, or the student
if 18
years or older, or an unaccompanied homeless youth (as defined by 42 USC 1434a) if a
suspected
deviation has been detected.
2.2.2.1 If a suspected deviation is detected, the school nurse shall refer the student for
further
evaluation through an on site follow up evaluation or a referral to the student’s health care
provider.
2.3 Lead Screening
2.3.1 Children who enter school at kindergarten or at age 5 or prior, shall be required to
provide

126

documentation of lead screening as per 16 Del.C. Ch. 26.
2.3.1.1 For children enrolling in kindergarten, documentation of lead screening shall be
provided within sixty (60) calendar days of the date of enrollment. Failure to provide
the required documentation shall result in the child's exclusion from school until the
documentation is provided.
2.3.1.2 Exemption from this requirement may be granted for religious exemptions, per 16
Del.C.
§2603.
2.3.1.3 The Childhood Lead Poisoning Prevention Act, 16 Del.C., Ch. 26, requires all health
care
providers to order lead screening for children at or around the age of 12 months of age.
2.3.2 The school nurse shall document the lead screening on the Delaware School Health
Record
form. See 14 DE Admin. Code 811.

Section B - 49 - 6-2005
DELAWARE SCHOOL PHYSICAL EXAMINATION FORM
To be completed by licensed medical physician, nurse practitioner or physician’s assistant.
Name: Sex: DOB:
Date: Examiner:
PLEASE CHECK IF CHILD HAS HAD DIFFICULTY WITH ANY OF THE FOLLOWING.
GIVE DATES AND ADDITIONAL INFORMATION UNDER COMMENTS.
[ ] ADD/ADHD [ ] Body Piercing/Tattoo [ ] Emotional [ ] Physical Disability
[ ] Allergies [ ] Bone/Spine [ ] Hearing [ ] Seizures
[ ] Asthma [ ] Bowel/Bladder [ ] Heart [ ] Speech
[ ] Behavior [ ] Chicken Pox [ ] Infections [ ] Surgery
[ ] Bleeding [ ] Diabetes [ ] Kidney [ ] Vision
[ ] OTHER
Comments:
Height: Weight: BP: Pulse:
Vision: Right Left
Hearing: Right Left
Lead Screening: Date Completed Results
Hematocrit/Hemoglobin: Date Completed Results
PPD (Mantoux): Date Placed Date Read Results (in mm)
or
TB Risk Assessment: Date Completed Results
3. Immunizations – Shaded Vaccines Required
DTP/Hib 1
//
DTP/Hib 2
//
DTP/Hib 3
//
DTP/ Hib 4
//
DTaP/Hib 4
//
DTP/DTaP 1
//
DTP/DTaP 2
//
DTP/DTaP 3
//
DTP/DTaP 4
//
DTP/DTaP 5
//
DT/Td 1
//

127

DT/Td 2
//
DT/Td 3
//
DT/Td 4
//
DT/Td 5
//
OPV/IPV 1
//
OPV/IPV 2
//
OPV/IPV 3
//
OPV/IPV 4
//
OPV/IPV 5
//
MMR 1
//
MMR 2
//
HepB 1
//
HepB 2
//
HepB 3
//
Hib 1
//
Hib 2
//
Hib 3
//
Hib 4
//
Hep B 1 (2 dose
Version Only)
//
Hep B 2 (2 dose
Version Only)
//
Hep B/Hib 1
//
Hep B/Hib 2
//
Hep B/Hib 3
//
Varicella 1
//
Varicella 2
//
Lyme Vax 1
//
Lyme Vax 2
//
Lyme Vax 3
//
Pneumococcal
Conjugate 1
//
Pneumococcal
Conjugate 2
//
Pneumococcal
Conjugate 3
//
Pneumococcal
Conjugate 4

128

//
Pneumococcal
Polysaccharide1
//
Pneumococcal
Polysaccharide 2
//
Hep A 1
//
Hep A 2
//
Influenza 1
//
Influenza 2
//
Other:
//
Other:
//
Page 1 of 2

Section B - 50 - 6-2005
CHILD’S NAME
PHYSICAL
EXAMINATION
Check (_)
NORMAL ABNORMAL
COMMENTS
General Appearance
Head/Scalp
Eyes
Ears
Nose/Throat
Mouth/Teeth/Gums
Heart
Chest/Lungs
Skin
Abdomen/Hernia
Genitalia
Neurological
Developmental
Musculoskeletal
Nutrition

Health Concerns or Special Needs Identified:
FOR CHRONIC CONDITIONS:
Please attach care plan, protocols, and/or emergency care plan.
Children with life-threatening conditions need an emergency care plan in
place.
Recommendations or Referrals:
Examiner’s Signature: Date:
Printed Name Phone Number:
Address:
Page 2 of 2

Section B - 51 - 6-2005

DELAWARE INTERSCHOLASTIC ATHLETIC ASSOCIATION
Parents/Guardian: The DIAA pre-participation physical evaluation and consents form
is a five
129

page document. Pages one, two and four require your signature while page five is a
reference for
you to keep. This physical evaluation must be completed after May 1 of the current
year playing
sports and runs through June 30 of the following year.

Athlete: _________________ Phone: ___________ School: _____________
Age:________ Gender: ________ Date of Birth: _________ Grade: ______
Parent/Guardian Name: (Please Print) ____________________________________
PARENT/GUARDIAN CONSENTS
________________________ Has my permission to participate in all
interscholastic
(Name of Athlete) sports not checked below.

If you check any sport in this box it means the athlete will not be permitted to participate in
that sport.

Collision Contact Non-Contact

__ football _ ice hockey __ volleyball ___ softball __ cross country ___tennis
__ soccer _ boys’ lacrosse __ field hockey ___ baseball __ swimming ___golf
__wrestling __ basketball ___ girls lacrosse __ track ___crew
__ squash __ cheerleading
1. My permission extends to all interscholastic activities whether conducted on or
off school premises. I
have read and discussed page 5, which is the list of items that protect against the
loss of athletic
eligibility, with said participant and I will retain that page for my reference. I have
also discussed with
him/her and we understand that physical injury, including paralysis, coma or death
can occur as a result
of participation in interscholastic athletics. I waive any claim for injury or damage
incurred by said
participant while participating in the activities not checked above.
Parent Signature:______________________________ Date: ___________________
2. To enable DIAA and its full and associate member schools to determine whether
herein named student is
eligible to participate in interscholastic athletics, I hereby consent to the release of
any and all portions of
school record files, beginning with the sixth grade, of the herein named student,
including but not limited
to, birth and age records, name and residence of student’s parent(s), guardian(s) or
Relative Care Giver,
residence of student, health records, academic work completed, grades received
and attendance records.
Parent Signature:______________________________ Date: ___________________
3. I further consent to DIAA’s and its full and associate member schools use of the
herein named student’s
name, likeness, and athletically related information in reports of interscholastic
practices, scrimmages or
contests, promotional literature of the Association, and other materials and releases
related to
interscholastic athletics.
Parent Signature:______________________________ Date: ___________________
130

4. By this signature, I hereby consent to allow the physician(s) and other health care
providers(s) selected
by myself or the schools to perform a pre-participation examination on my child and
to provide treatment
for any injury received while participating in or training for athletics for his/her
school. I further consent
to allow said physician(s) or health care provider(s) to share appropriate information
concerning my child
that is relevant to participation, with coaches, medical staff, Delaware
Interscholastic Athletic
Association, and other school personnel as deemed necessary. Such information
maybe used for injury
surveillance purposes.
Parent Signature:______________________________ Date: _________________

Section B - 52 - 6-2005

DIAA Preparticipation Physical Evaluation HISTORY FORM
DATE OF EXAM
Name Sex Age Date of birth
Grade School Sport(s)
Address Phone
Personal physician
In case of emergency, contact
Name Relationship Phone (H) (W)
Explain “YES” answers below.
Circle questions you don’t know the answers to.
Yes No
1. Has a doctor ever denied or restricted your
participation in sports for any reason? _ _
2. Do you have an ongoing medical condition
(like diabetes or asthma)? _ _
3. Are you currently taking any prescription or
nonprescription (over-the-counter) medicines or pills? _ _
4. Do you have allergies to medicines, pollens, foods,
or stinging insects? _ _
5. Have you ever passed out or nearly passed out
DURING exercise? _ _
6. Have you ever passed out or nearly passed out
AFTER exercise? _ _
7. Have you ever had discomfort, pain, or pressure in
your chest during exercise? _ _
8. Does your heart race or skip beats during exercise? _ _
9. Has a doctor ever told you that you have
(check all that apply):
_ High blood pressure _ A heart murmur
_ High cholesterol _ A heart infection
10. Has a doctor ever ordered a test for your heart?
(for example, ECG, echocardiogram) _ _
11. Has anyone in your family died for no apparent reason? _ _
12. Does anyone in your family have a heart problem? _ _
13. Has any family member or relative died of heart
problems or of sudden death before age 50? _ _
14. Does anyone in your family have Marfan syndrome? _ _
15. Have you ever spent the night in a hospital? _ _
16. Have you ever had surgery? _ _
17. Have you ever had an injury, like a sprain, muscle or
ligament tear, or tendinitis, that caused you to miss a
practice or game? If yes, circle affected area below: _ _
18. Have you had any broken or fractured bones or
dislocated joints? If yes, circle below: _ _
19. Have you had a bone or joint injury that required x-rays,

131

MRI, CT, surgery, injections, rehabilitation, physical
therapy, a brace, a cast, or crutches? If yes, circle below: _ _
Head
Neck
Shoulder
Upper
arm
Elbow
Forearm
Hand/
fingers
Chest
Upper
back
Lower
back
Hip
Thigh
Knee
Calf/shin
Ankle
Foot/toes

20. Have you ever had a stress fracture? _ _
21. Have you been told that you have or have you had
an x-ray for atlantoaxial (neck) instability? _ _
22. Do you regularly use a brace or assistive device? _ _
23. Has a doctor ever told you that you have asthma
or allergies? _ _
24. Do you cough, wheeze, or have difficulty breathing
during or after exercise? _ _
25. Is there anyone in your family who has asthma? _ _
26. Have you ever used an inhaler or taken asthma medicine? _ _
27. Were you born without or are you missing a kidney,
an eye, a testicle, or any other organ? _ _
28. Have you had infectious mononucleosis (mono)
within the last month? _ _
29. Do you have any rashes, pressure sores, or other
skin problems? _ _
30. Have you had a herpes skin infection? _ _
31. Have you ever had a head injury or concussion? _ _
32. Have you been hit in the head and been confused
or lost your memory? _ _
33. Have you ever had a seizure? _ _
34. Do you have headaches with exercise? _ _
35. Have you ever had numbness, tingling, or weakness
in your arms or legs after being hit or falling? _ _
36. Have you ever been unable to move your arms or
legs after being hit or falling? _ _
37. When exercising in the heat, do you have severe
muscle cramps or become ill? _ _
38. Has a doctor told you that you or someone in your
family has sickle cell trait or sickle cell disease? _ _
39. Have you had any problems with your eyes or vision? _ _
40. Do you wear glasses or contact lenses? _ _
41. Do you wear protective eyewear, such as goggles or
a face shield? _ _
42. Are you happy with your weight? _ _
43. Are you trying to gain or lose weight? _ _
44. Has anyone recommended you change your weight
or eating habits? _ _
45. Do you limit or carefully control what you eat? _ _
46. Do you have any concerns that you would like to
discuss with a doctor? _ _
FEMALES ONLY
47. Have you ever had a menstrual period? _ _
48. How old were you when you had your first menstrual period?
49. How many periods have you had in the last 12 months?
Explain “Yes” answers here:

I hereby state that, to the best of my knowledge, my answers to the above questions are complete and
correct.
Signature of athlete Signature of parent/guardian Date
© 2004 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American
Medical Society
for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine.

132

2 PREPARTICIPATION PHYSICAL EVALUATION

Section B - 53 - 6-2005

DIAA PRE-PARTICIPATION PHYSICAL EVALUATION
Name___________________________________________________ Date of
Birth_______________________
Height__________ Weight_________ %Body fat (optional)__________ Pulse__________
BP___/___(___/___)
Vision R 20/___ L20/___ Corrected: Y N Pupils: Equal____ Unequal____ Risk behaviors
discussed: Y N
(diet, weight, driving, drugs, alcohol, sexuality, safety, stress)

Please choose one of the following four (4) options:
___1. Cleared without restriction
___2. Cleared, with recommendations for further evaluation or treatment for:
_________________________________________________________________________________________

___3. *Not Cleared, but needs additional evaluation by
(whom):___________________________________________
___4. Not Cleared for either ___All sports ___Certain sports:____________________________________________
Reason:__________________________________________________________________________________
Please note any necessary equipment, medications, or restrictions for cleared athlete to play or
practice:
By this signature, I hereby state that I have performed a pre-participation examination in accordance
with DIAA standards (current
edition of Physician and Sports Medicine’s Pre-participation Physical Evaluation) and certify that the
above clearance and attached PPE
is accurate, complete and compliant to such standards. I also agree that I have documented and
signed any playing restrictions on the
High School Athlete Medical Card (pg 4).
HealthCare Provider’s Signature:________________________________________ Date:________________
Printed Name:____________________________________ Title:_______________ Phone:_______________
*If Option 3 checked then Referred Physician needs to complete below:
____ Cleared- no restriction _____Cleared with the following restrictions:________________________________
____ Not Cleared for ___All sports ___Certain sports:_____________________________________________
Referred Physician Signature:______________________________Print:____________________ Date:__________

NORMAL ABNORMAL FINDINGS INITIALS*
MEDICAL
Appearance
Eyes/ears/nose/throat
Hearing
Lymph nodes
Heart
Murmurs
Pulses
Lungs
Abdomen
Genitourinary(males
only)+
Skin
MUSCULOSKELETAL
Neck
Back
Shoulder/arm
Elbow/forearm
Wrist/hand/fingers
Hip/thigh
Knee
Leg/ankle
Foot/toes
*Multiple-examiner set-up only +Having 3rd party present is recommended for the genitourinary exam
Notes:

Section B - 54 - 6-2005

SCHOOL ATHLETE MEDICAL CARD
133

(Parent/Guardian: please print and complete Sections 1, 2 & 3)
For office use only: This card is valid from May 1, 20_______ through June 30, 20________
Note: If any changes occur, a new card should be completed by the parent/guardian. The
original card should be
kept on file in the school athletic director’s or athletic trainer’s office. A copy should be kept
in the sports’ athletic
kits. This card contains personal medical information and should be treated as confidential
by the school, its
employees, agents, and contractors.
Name of School: ______________________________ Name of ATC: _____________________________
Section 1: CONTACT/PERSONAL INFORMATION
NAME:____________________________________________ SPORT:________________
SS#:________________
AGE:____GRADE:____ BIRTH DATE:___________ GUARDIAN
NAME:__________________________________
ADDRESS:___________________________________________________________________________________
___
PHONE: (H)_____________________ (W)_________________ (C)_________________
(P)_________________
Other authorized person to contact in case of emergency:
NAME:__________________________________________
PHONE(s):______________________________________
NAME:__________________________________________
PHONE(s):______________________________________
Preference of Physician (and permission to contact if needed):
NAME:___________________________________________________
PHONE:_____________________________
HOSPITAL PREFERENCE:______________________
INSURANCE:_____________________________________
POLICY #:________________________ GROUP:_________________________
PHONE:____________________
Section 2: MEDICAL INFORMATION
MEDICAL
ILLNESSES:______________________________________________________________________________
LAST TETANUS (mo/yr):____________
ALLERGIES:_____________________________________________________
MEDICATIONS:_______________________________________________________________________________
_____
(any medications that may be taken during competition require a physician’s note)
PREVIOUS HEAD/NECK/BACK
INJURY:_______________________________________________________________
PREVIOUS HEAT-RELATED
PROBLEMS:______________________________________________________________
PREVIOUS SIGNIFICANT
INJURIES:__________________________________________________________________
ANY OTHER IMPORTANT MEDICAL
INFORMATION:__________________________________________________
Section 3: Consent for Athletic Conditioning, Training and Health Care Procedures
I hereby give consent for my child to participate in the school’s athletic conditioning and
training program, and to receive
any necessary healthcare treatment including first aid, diagnostic procedures, and medical
treatment, that may be provided
by the treating physicians, nurses, athletic trainers, or other healthcare providers employed
directly or through a contract by

134

the school, or the opposing team’s school. The healthcare providers have my permission to
release my child’s medical
information to other healthcare practitioners and school officials. In the event I cannot be
reached in an emergency I give
permission for my child to be transported to receive necessary treatment. I understand that
Delaware Interscholastic
Athletic Association or its associates may request information regarding the athlete’s health
status, and I hereby give my
permission for the release of this information as long as the information does not personally
identify my child.
Parent/Guardian Signature:_______________________________________ Date:_______________
Athlete’s Signature:_____________________________________________ Date:_______________
Section 4: Clearance for Participation
__ Cleared without restrictions __ Cleared with the following restrictions:
Health Care Provider’s Signature:_____________________________________ MD/DO, PA,NP
Date:__________

Section B - 55 - 6-2005

Protect Your Athletic Eligibility
YOU ARE NOT ELIGIBLE:
1. If you attend a high school and become 19 years of age before June 15. (Reg. 1009.2.1.1)
2. If you attend a junior high/middle school that terminates in the 8th grade and become 15 years of
age before June 15. (Reg.
1008.2.1.1.1)
*3. If you are not legally enrolled at the school which you represent. (Reg. 1008.2.3.1 and Reg.
1009.2.3.1)
4. If you are not residing with your custodial parent(s), court appointed legal guardian(s), Relative
Caregiver, or are a student 18 years
of age or older and living in the attendance zone of the school you attend unless you are participating
in the Delaware School Choice
Program, attend a private school or are a boarding school student. IF YOUR CUSTODIAL PARENT(S),
LEGAL
GUARDIAN(S) OR RELATIVE CAREGIVER(S) RELOCATES TO A DIFFERENT ATTENDANCE ZONE, YOU MUST
NOTIFY YOUR ATHLETIC DIRECTOR IMMEDIATELY. (Reg. 1008.2.2.1 and Reg. 1009.2.2.1)
*5. If you were absent unexcused or absent due to illness or injury; have been suspended (in-school or
out-of-school); or have been
assigned to homebound instruction or an alternative school for disciplinary reasons. (Reg. 1008.2.3.4
and 1008.2.3.5 Reg.
1009.2.3.5 and 1009.2.3.6)
6. If you failed to complete the preceding semester for reasons other than personal illness or injury.
(Reg. 1008.2.3.6; Reg. 1009.2.3.7)
*7. If you do not pursue a regular course of study and pass at least five credits per marking period
(equivalent of four credits in junior
high/middle school), two credits of which must be in the areas of Mathematics, Science, English, or
Social Studies. IF YOU ARE
A SENIOR, YOU MUST PASS ALL COURSES WHICH SATISFY AN UNMET GRADUATION REQUIREMENT.
(Reg.
1008.2.6.; Reg. 1009.2.6.1)
8. If you transferred and have not been in regular attendance at your receiving school for at least 90
school days unless the transfer was
the result of a change in residence by you and your custodial parent(s) or court appointed legal
guardian(s) from the attendance zone
of the sending school to the attendance zone of the receiving school or you transferred after the end of
the previous academic year
and completed registration at your receiving school before the first student day of the current
academic year. (Reg. 1008.2.4 and
Reg. 1009.2.4)
9. If you participated in the Delaware School Choice Program during the previous academic year and
transferred to your “home school”

135

for the current academic year without completing your two-year commitment or receiving a release
from the sending school. (Reg.
1008.2.3.3; Reg. 1009.2.3.4)
10. If you participated in the Delaware School Choice Program during the previous academic year and
transferred to another “choice
school” for the current academic year unless you are playing a sport not sponsored by the sending
school. (Reg. 1008.2.4.6.1; Reg.
1009.2.4.7.1)
11. If you reached the age of majority (18), occupied a residence in a different attendance zone than
your custodial parent(s) or court
appointed legal guardian(s), and have not been in regular attendance at your receiving school for at
least 90 school days unless you
are participating in the Delaware School Choice Program and your application was properly submitted
prior to your change of
residence. (Reg. 1009.2.2.1.7)
12. If you attend a high school and more than four years has elapsed since you first entered 9th grade,
or more than five years has
elapsed since you just entered 8th grade in schools with 8th grade eligibility for high school sports. (Reg.
1009.2.7.1 and 2.7.2.1)
13. If you attend a junior high/middle school in which only grades 7-8 are permitted to participate in
interscholastic athletics and
more than two years has elapsed since you first entered 7th grade. (Reg. 1008.2.7.1)
14. If you attend a junior high/middle school in which grades 6-8 are permitted to participate in
interscholastic athletics and
more than three years has elapsed since you first entered 6th grade. (Reg. 1008.2.7.2)
15. If you have played on or against a professional team or have accepted cash or a cash equivalent
(savings bond, certificate of deposit,
etc.); a merchandise item(s) with an aggregate retail value of more than $150; a merchandise
discount; a reduction or waiver of fees;
a gift certificate or other valuable consideration for athletic participation. (Reg. 1009.2.5.1.4 and
2.5.1.5)
16. If you have used your athletic status to promote a commercial product or service in an
advertisement or personal appearance. (Reg.
1009.2.5.1.7)
17. If you have not received a physical examination from a licensed physician (M.D. or D.O.), a certified
nurse practitioner or a certified
physician’s assistant on or after May 1 and written consent from your custodial parent(s) or court
appointed legal guardian(s) to
participate in interscholastic athletics is not on file in the school office. (Reg. 1009.3.1.1.1 and Reg.
1008.3.1.1)
18. If you participate in an all-star game not approved by DIAA before you graduate from high school.
(Reg. 1009.5.4)
19. If you are a foreign exchange student not participating in a two-semester program listed by the
Council on Standards for
International Educational Travel (CSIET). (Reg. 1009.2.8.1.2)
20. If you are an international student not in compliance with all DIAA regulations including Reg.
1009.2.2 residency requirements.
(Reg. 1009.2.8.2)
*IF YOU ARE NOT IN COMPLIANCE WITH THESE REQUIREMENTS, YOU MAY NOT PRACTICE, SCRIMMAGE
OR
PLAY IN A GAME.
NOTE: Consult with your coach, athletic director, or principal for information concerning additional
eligibility requirements.

Section B - 56 - 6-2005
STUDENT HEALTH HISTORY UPDATE
This information will be shared on a need to know basis with staff, administration and emergency medical staff in
the case of an
emergency unless you notify us otherwise.

Date Parent/Guardian’s Signature
Student DOB: Grade Teacher
136

PLEASE CHECK IF CHILD HAS HAD DIFFICULTY WITH ANY OF THE FOLLOWING. GIVE
DATES AND ADDITIONAL INFORMATION UNDER COMMENTS.
1. [ ] ADD/ADHD [ ] Body Piercing/Tattoo [ ] Emotional [ ] Physical Disability
[
[
[
[
[

]
]
]
]
]

Allergies [ ] Bone/Spine [ ] Hearing [ ] Seizures
Asthma [ ] Bowel/Bladder [ ] Heart [ ] Speech
Behavior [ ] Chicken Pox [ ] Infections [ ] Surgery
Bleeding [ ] Diabetes [ ] Kidney [ ] Vision
OTHER

Comments:
2. Does your child have allergies to medicine, food, latex or insect bites?
NO [ ] YES [ ] To What What happens
Treatment
3. Has your child had any illnesses since school ended in June?
NO [ ] YES [ ] Type of illness, with date(s)
4. Has your child had surgery since school ended in June?
NO [ ] YES [ ] Type of surgery, with date(s)
5. Has your child received any immunizations since school ended in June?
NO [ ] YES [ ] List immunizations, with dates
6. Is your child being treated or evaluated for any health conditions?
NO [ ] YES [ ] List condition
7. Is your child on any medication or treatment?
NO [ ] YES [ ] Name of medication and/or treatment
Does your child need medicine during school hours?
NO [ ] YES [ ] *If yes, please contact the school nurse to make arrangements.
8. Has your child ever been examined by an eye doctor?
NO [ ] YES [ ] Date of last exam
NO [ ] YES [ ] Glasses Prescribed
If your child wears glasses or contact lenses, when was the prescription last
changed
9. Has your child had any emotional upsets (recent move, death, separation,
divorce) since school ended
in June?
NO [ ] YES [ ] List
10. What is the name of your child’s dentist?
What is the date of his/her last dental exam?
11. What is the name of your child’s primary healthcare provider?
What is the date of his/her last physical exam?
Thank you.

Section B - 57 - 6-2005

Lead Screening Program

Current Program
The Childhood Lead Poisoning Prevention Act requires all healthcare
providers to order
screening for children at or around 12 months of age. “Child care facilities,
public and private
nursery schools, preschools and kindergartens shall require screening for
lead poisoning for
admission or continued enrollment.”

137

Schools are responsible for informing parents of this mandate at the time of
registration for PreK
or Kindergarten. Documentation that a blood lead test was completed must
be on file in the
Student Health Record. Results of the test are not required although
encouraged. Schools
should work with families of children with high blood levels to assure followup and appropriate
treatment. Families failing to provide documentation should be notified early
in the school year.
Children without documentation will be excluded from school after 60 days of
the date of
enrollment.
History
In 1995, legislation was passed requiring lead exposure. Its goal is the
foundation of today’s
program: to assure all Delaware children have reduced exposure to lead and
receive early
identification.
In 2001, the Division of Public Health reported that 1.4% of Delaware children
screened had
levels above 10 microgram. The national average at that time was 4.4%.
With Delaware’s
mandated blood lead testing for school entry at PreK or Kindergarten, the
number of children
tested in Delaware continues to rise as the number of children with elevated
blood levels
continues to decline.
Overview of Lead Poisoning
Lead has existed since antiquity and occurs naturally in the environment.
Egyptians used lead in
mascara and the United States later used it in paint, plumbing and gasoline.
Paint containing
lead was banned in the late 1970’s; however, the military continued to use it.
Lead poisoning is
a silent disease with subtle, if any, signs and symptoms, but very damaging
because it affects soft
tissues of the body (ex. brain, kidneys, bone, etc.) and can be passed
through the placenta to a
fetus. Lead poisoning effects concentration and the ability of children to
learn. High blood
levels have been associated to lower IQs. Lead poisoning can be obtained by
inhalation or water,
but the most common mode is hand-to-mouth. More than 80% of houses
built prior to 1950-55
have lead even if well maintained.
138

While lead poisoning is more likely to occur in early childhood, older children
and adults can
also be exposed and affected. In 2005 the CDC issued Recommendations for
Lead Poisoning in
Newly Arrived Refugee Children. The report noted: “Although blood lead
levels (BLLs) in
children aged 1 to 5 years are decreasing in the United States, the
prevalence of elevated BLLs
among newly resettled refugee children is substantially higher than children
born in the United
States.” The complete Recommendations for Lead Poisoning in Newly Arrived
Refugee Children
Section B - 58 - 6-2005
are available online at www.cdc.gov/nceh/lead. In Delaware, Medicaid will
cover testing costs
for newly arrived refugee children. Possible exposure, signs and symptoms
include:
Exposure:
Breathing air or dust with lead
• Dust from lead-based paint
• Work-site where lead paint is used
• Certain hobbies (stained glass, home renovation, removing lead paint,
making lead
fishing weights, etc.)
Ingesting contaminated food/water
Non-western cosmetics
Health-care products, not produced in the U.S., with lead
Folk remedies with lead
Improperly glazed pottery, ceramic dishes or leaded-crystal glassware
Lead piping for plumbing
Signs/Symptoms associated with lead poisoning:
Poor concentration
Anemia
Weakness in fingers, wrists or ankles
Decreased reaction time
Mental retardation
Decreased physical growth
Resources
www.cdc.gov/lead
www.cdc.gov/nceh/lead
Section B - 59 - 6-2005

IV. Screening
Section B - 60 - 7-2007

815 Physical Examinations and Screening
1.0 Physical Examinations

139

1.1 All public school students shall have a physical examination that has been administered
by a licensed
medical physician, nurse practitioner or physician's assistant. The physical examination shall
have been
done within the two years prior to entry into school. Within fourteen calendar days after
notification of the
requirement for a physical examination, new enterers shall have received a physical
examination or shall have
a documented appointment with a licensed health care provider for a physical examination.
1.1.1The requirement for the physical examination may be waived for students whose
parent, guardian or Relative
Caregiver, or the student if 18 years or older, or an unaccompanied homeless youth (as
defined by 42 USC
11434a) presents a written declaration acknowledged before a notary public, that because
of individual
religious beliefs, they reject the concept of physical examinations.
1.1.2 The school nurse shall record all findings on the Delaware School Health Record Form
(see 14 DE
Admin. Code 811) and maintain the original copy in the child’s medical file.
NON REGULATORY NOTE: See 14 DE Admin. Code 1008.3 and 14 DE Admin. Code 1009.3 for
physical examination requirements associated with participation in sports.
2.0 Screening
2.1 Vision and Hearing Screening
2.1.1 Each public school student in kindergarten and in grades 2, 4, 7 and grades 9 or 10
shall receive a vision
and a hearing screening by January 15th of each school year.
2.1.1.1 In addition to the screening requirements in 2.1.1, screening shall also be provided to
new
enterers, students referred by a teacher or an administrator, and students considered for
special
education.
2.1.1.1.1 Driver education students shall have a vision screening within a year prior to their
in car
driving hours.
2.1.2 The school nurse shall record the results on the Delaware School Health Record Form
and shall notify the
parent, guardian or Relative Caregiver or the student if 18 years or older, or an
unaccompanied homeless
youth (as defined by 42 USC 11434a) if the student has a suspected problem.
2.2 Postural and Gait Screening
2.2.1 Each public school student in grades 5 through 9 shall receive a postural and gait
screening by December
15th.
2.2.2 The school nurse shall record the findings on the Delaware School Health Record Form
(see 14 DE
Admin. Code 811) and shall notify the parents, guardian or Relative Caregiver, or the student
if 18
years or older, or an unaccompanied homeless youth (as defined by 42 USC 11434a) if a
suspected
deviation has been detected.
2.2.2.1 If a suspected deviation is detected, the school nurse shall refer the student for
further
evaluation through an on site follow up evaluation or a referral to the student’s health care
provider.
2.3 Lead Screening

140

2.3.1 Children who enter school at kindergarten or at age 5 or prior, shall be required to
provide
documentation of lead screening as per 16 Del.C. Ch. 26.
2.3.1.1 For children enrolling in kindergarten, documentation of lead screening shall be
provided within
sixty (60) calendar days of the date of enrollment. Failure to provide the required
documentation
shall result in the child's exclusion from school until the documentation is provided.
2.3.1.2 Exemption from this requirement may be granted for religious exemptions, per 16
Del.C.
§2603.
2.3.1.3 The Childhood Lead Poisoning Prevention Act, 16 Del.C., Ch. 26, requires all health
care
providers to order lead screening for children at or around the age of 12 months of age.
2.3.2 The school nurse shall document the lead screening on the Delaware School Health
Record form
form. See 14 DE Admin. Code 811.

Section B - 61 - 6-2005
Vision Screening Procedures
The American Optometric Association identifies seven vision skills that are
needed in school:
near vision, distance vision, binocular coordination, eye movement skills,
focusing skills,
peripheral awareness, and eye/hand coordination
(http://www.aoa.org/x1802.xml). The primary
goal of school vision screening is early identification and referral of children
with visual
abnormalities which can interrupt educational, physical and emotional
growth.
I. Preparation
A. Obtain class rosters to use as a worksheet and to record results of screening, if
results are not
directly entered in a computer program.
B. Notify parents (school newsletter, note, other), students and faculty of upcoming
screening.
C. Schedule screenings to assure completion by January 15.
D. Review equipment and manufacturer’s directions.
II. External Exam
During vision screening the school nurse has the opportunity to observe for other
signs/symptoms
which could indicate conditions that should be referred for further evaluation.
• Alignment of the eyes, symmetry
• Red or swollen eyelids
• Drainage from the eyes or abnormal conjunctiva
• Pruitis
• Red, pink, bluish-tone or yellow-stained sclera
• Cloudy appearance of lens or cornea
• Pupil size
III. Acuity
If corrective lenses are usually worn by the student, all testing should be done with
the glasses in
141

place.
A. Non Instrument (appropriate for Grade Pre-K-adult)
1. Equipment Needed
a. Lighted chart (Snellen, Good Lite, Instaline, NOTV) or graduated cards (ex.
Lighthouse, Blackbird)
b. Plastic occluder
c. Plus lens: +2.25 and +1.75 lens
d. Near Vision Card
e. Quiet room at least 20 feet in length (or 10 feet if using 10-foot chart) with
adequate
lighting
(1) Illumination of chart, evenly diffused over chart without glare
(2) General illumination not less than 1/5 of chart illumination and nothing in the
field of vision brighter than the chart
2. Recommended Procedures
a. Distance Vision Acuity (appropriate screening tool for Grades Pre-K through adult)
(1) Place the child at a mark exactly 20 feet or 10 feet, depending upon the chart
used, from the chart with the eye level at the 20/20 or 10/10 line. If standing, the
heels should be on the 20 or 10-foot mark. If seated, the back legs of the chair
should be on the mark.
(2) Children with prescriptive glasses for distance should be tested wearing the
glasses.
(3) Prior to screening review the symbols or letters with the child to ascertain the
child’s ability to recognize and communicate the symbol.
(4) Teach the child to use the occluder to cover one eye while keeping both eyes
open during test.
(5) Expose one symbol or letter at a time.

Section B - 62 - 6-2005

(6) Test the right eye first, then the left, then both eyes.
(7) Begin with the 30 or 40-foot line and proceed to include the 20-foot line. With
children suspected of low vision, begin with the 200-foot line.
(8) Move rhythmically from one symbol to another at a pace that is comfortable to
the child. Reading the majority (i.e., more than half) of the symbols on a line is
considered passing.
(9) Observe for thrusting head forward, tilting head, eyes watering, frowning or
scowling, closing one eye during the test of both eyes together, and excessive
blinking.
(10) Stop when the child fails a line and record last line read correctly. Record visual
acuity in order given for the right eye, left eye, for both eyes. Numerator equals
distance from the chart; denominator represents the line read (20/60 means 20
feet distance over 60-foot line.)
(11) A second screening is recommended on all children who fail prior to referral.
b. Near Vision – using plus lens or chart
(1) Plus lens (testing hyperopia)
(a) Place the plus lens glasses on the child. Use small framed (+2.25) glasses for
preschool through second grade and larger framed (+1.75) glasses for third
grade and up.
(b) As before, show the symbol at 20 feet or 10 feet and ask the child to read the
20-foot or 10-foot line.
(c) If a child is able to read with either eye the 20/20 or 10/10 line through a plus
142

lens, he/she fails.
(2) Chart
(a) Review the symbols or letters on the chart with the child and ascertain the
child’s ability to recognize and communicate the symbol.
(b) Hold/place the child’s head at the distance directed by manufacturer
(typically 13” or 16”).
(c) Occlude each eye, alternately, to screen individually and then test binocular
vision.
(d) Stop when the child fails a line and record last line read correctly.
3. Screening Failure Criteria
a. Grades Pre-K and Kindergarten:
(1) Children with vision 20/50, or
(2) Repeated screening of 20/40 with other visual concerns or learning problems;
visual complaints.
b. Grade 1 and above:
(1) Children with vision 20/40 or less, or
(2) Screening of 20/30 with other visual concerns or learning problems; visual
complaints.
c. Unequal screening acuity between eyes of more than one line.
d. Ability to read the 20/20 or the 10/10 line with either eye through the plus lens.
B. Instrument (recommended for children in Grades 3 and up)
1. Equipment Needed
a. Stereoscopic Instrument (ex. Titmus)
b. Quiet room with adequate lighting as recommended by manufacturer
2. Recommended Procedures
a. Distance and Near Vision
(1) Follow instructions outlined by maker of instrument to test each eye.
(2) Assure the child’s head is correctly placed up against machine.
3. Screening failure criteria (See A.3. above)
IV. Muscle Tests

Section B - 63 - 6-2005

A. Non Instrument (appropriate screening tool for Grade K-adult)
1. Equipment Needed
a. Occluder
b. Test object: something handheld that the child can focus on (ex: sticker on finger,
pencil puppet, pen light)
2. Recommended Procedures
a. Cover/uncover tests (near and far)
(1) Hold the test object about 14 inches from the child and instruct him/her to look
at
the object. Talk to him/her and ask questions about the object so he/she won’t
stare but will actually look at it.
(2) Cover the right eye with the occluder. Observe the left eye for movement.
Cover the right eye again and observe for movement of the right eye.
(3) Repeat technique for left eye.
(4) Repeat as many times as it takes to be sure of the result. The occluder should be
moved quickly without touching the child’s face.
(5) Repeat the procedure using a test object at 10 or 20-feet away.
b. Tracking
(1) Hold test object approximately 16” from patient’s eye
143

(2) Move object to all four quadrants in “H” pattern
(3) Move object towards nose
(4) Observe for stramisbus, nystagmus, diplopia, convergence, and smoothness of
movement.
c. Screening Failure Criteria
(1) Cover test: If either eye moves in or out to see the object, or is unsteady. Record
–(minus) for failing, +(plus) for passing.
(2) Tracking: Signs of difficulty in any area.
B. Instrument (appropriate screening tool for Grade 3-adult)
1. Equipment Needed
a. Stereoscopic Instrument (ex. Titmus)
b. Quiet room with adequate lighting as recommended by manufacturer
2. Follow instructions outlined by maker of instrument to test each eye.
3. Assure the child’s head is correctly placed up against machine.
V. Depth Perception (recommended screening tool for Grade K and for new enterers
not previously
screened)
A. Non Instrument (appropriate screening for Grade K-adult)
1. Equipment Needed
a. Stereo test
b. Polaroid glasses for depth perception
2. Recommended Procedures
a. Place the special glasses on the child.
b. Hold the picture of the fly sixteen inches away, avoiding reflection on the shiny
surface.
c. Have the child try to “pinch” the fly’s wings using the thumb and forefinger. (It
may
aid the preschool age child to show him how to “pinch” before he sees the fly.) If the
eyes are functioning properly, the child will see the fly as a solid, three-dimensional
object and the fingers will not touch the picture.
3. Screening Failure Criteria – The child fails the test if his fingers touch the picture,
meaning
that he/she sees it as an ordinary, flat photograph. Record the results, +(plus) for
passing, (minus) for failing.
B. Instrument (appropriate screening tool for Grade 3-adult. Refer to #I.B. for
guidelines.)
1. Equipment Needed
a. Stereoscopic Instrument (ex. Titmus)

Section B - 64 - 6-2005

b. Quiet room with adequate lighting as recommended by manufacturer
2. Recommended procedures
a. Follow instructions outlined by maker of instrument to test each eye.
b. Assure the child’s head is correctly placed up against machine.
VI. Color Vision (recommended screening for Grade K and new enterers not
previously screened)
A. Equipment Needed – Ishihara or Hardy-Rand-Rittler Pseudoisochromatic Plates
B. Recommended Procedures
1. Follow instructions as outlined in the manufacturer’s directions.
2. Adequate lighting.
144

C. Screening Failure Criteria – Any child who cannot discriminate colors.
VII. Common Mistakes Screeners Make:
A. Not being organized
B. Not knowing how to use the testing equipment
C. Not testing equipment first to make sure it work
D. Failing to check student’s health record before vision screening to note whether
the child
already wears glasses, but doesn’t have them with him/her
E. Assuming children know their letters in kindergarten or assuming children know
the English
words for the letters/symbols
F. Failing to provide privacy
G. Making sure equipment fits correctly
H. Making sure student is properly positioned (ex. Resting forehead on machine, or
heels on 20’
line)
I. Screening without glasses
J. Assuming child is looking at same line or reading in proper direction you are
indicating
K. Thinking that assessment equals intervention
L. Not following up on referrals
M. Not utilizing the services of the Lion’s Club for vision/glasses
VIII. Follow-Up
A. Record test results on the School Health Record.
B. Referral
1. Students under professional care need not be referred, but should be followed to
encourage
continuity of appropriate treatment.
2. Notify parent/guardian that child has a suspected visual problem (see “Sample,”
Section B,
page 65). They should be advised to seek further examination from an
ophthalmologist or
optometrist. If the family cannot afford to have the child seen privately, a referral
may be
made to the Optometric Clinic in the County Health Unit. Contact the clinic for
eligibility.
C. Meeting student’s immediate needs
1. Discuss suspected or known deviations with appropriate school personnel.
2. Color deficiency is not correctable, but parent/guardian and students should be
made aware
of this condition and its implications.
IX. Visually Impaired Students
Medical assistance and educational services may be received through the Division
for the Visually
Impaired, 305 West 8th Street, Wilmington, Delaware 19801 (577-3333).
X. Resource Information
Assessing Visual Status in Schools, National Association of School Nurses, 2005.

Section B - 65 - 6-2005
SAMPLE
Date

145

Dear Parent/Guardian:
A recent vision screening test at school indicates that____________________________
(student and grade)
may have some vision difficulty. An eye examination is recommended. Please take
this form with you at the time of examination.
(School Nurse)
(School)
REASON FOR REFERRAL
Vision Test Results
______Frequent headaches after reading ______Blinking ______Blurred Vision
______Squinting ______Watering Eyes
Remarks

EYE EXAMINER’S REPORT TO SCHOOL
______Glasses Prescribed ______Not Prescribed
____To be worn at all times.
____To be worn at all times except during physical education.
____To be worn for driving.
____To be worn in the classroom.
____Preferential Seating
______Vision to be expected with correction: R 20/ L 20/
______When should student return for reexamination?
We would appreciate any additional information which may be pertinent to this student’s
school adjustment.
Date
Signature of Eye Examiner
NOTE: Please complete and return to the school nurse. Thank you.
School Nurse Address
School Nurse Fax

Section B - 66 - 6-2005
Hearing Screening Procedures
The ability to communicate effectively impacts the well-being of a child, in
terms of education,
physical and social development. Early identification and intervention of
hearing loss is critical
in supporting speech/language development and full participation in the
learning process. Even
mild hearing losses may be educationally and medically significant.
I. Preparation
A. Obtain class rosters to use as a worksheet and to record results of
screening, if results are
not directly entered in a computer program (see “Class Record Form,”
Section B, page
69).
B. Notify parents (school newsletter, note, other), students and faculty of
upcoming
screening.
C. Schedule screenings to assure completion by January 15.
D. Review equipment and manufacturer’s directions.
E. Testing area should be:

146

1. Quiet and free from ambient noises such as fans, typewriters, blowers,
flushing
toilets, band rehearsals, gymnasiums, or playgrounds. Experience has shown
that
rooms treated with acoustical tile, heavy drapes covering windows,
carpeting, and
solid core doors help to eliminate extraneous noise.
2. Of sufficient size to accommodate the evaluator and the student. In some
cases it is
helpful to have space that permits the seating of 2 to 4 additional students
so that they
may observe the test procedure.
3. Supplied with an electrical outlet (110V AC).
F. Set up a table sufficient in size to accommodate the audiometer and
provide the evaluator
with ample writing space. Seating for the tester and the student should be of
appropriate
size.
G. Assemble necessary forms: class roster for recording results,
parent/guardian letter, and
referral form.
H. Children with hearing aids or a medical diagnosis of hearing loss do not
require screening
further.
II. External Exam
A. Hearing screening affords the opportunity to observe for the following and
make
appropriate referrals:
1. Hair/scalp conditions
2. Piercings, which may be un-healed or may interfere with alignment of
headphones
during procedure
3. Drainage or cerumen from ear
III. Acuity
A. Equipment needed
1. Pure tone audiometer, calibrated annually to current ANSI standards.
B. Recommended procedure
1. Turn on audiometer. Some manufacturers recommend allowing the
machine to
warm up for 15-20 minutes. Leave the machine on for the entire screening
period.
2. Always test the audiometer before using it. (Test it on yourself.)
3. Arrange the chairs so the student cannot view the equipment or the
recording sheet.
4. Give directions to the student on an appropriate response to hearing the
tone.
147

Section B - 67 - 6-2005
5. Place earphones on the student’s head, being sure to line up the
microphone with
the student’s ear canal. Typically, the red earphone goes on the right ear. It
may be
necessary to remove earrings, headbands and glasses.
6. Screening should be performed only at the following frequencies: 1000,
2000,
and 4000 Hertz (Hz).
7. Intensity level of screenings will be 20 decibels (dB) at each frequency.
(NOTE: If
there appears to be a fair amount of extraneous noise, screening intensity
level can
be raised to 25 dB for each frequency.) Press the tone for 2-4 seconds. Vary
the
interval between tones.
8. Only clean the rubber earphones with a lightly damp cloth. Do not put
liquid on
the microphones which are located in the center of each earphone!
NOTE: Some students with significant limitations may be incapable of
screening
via the traditional audiometric screening as described in this section. For
these students, the school may elect to purchase specialized equipment to
facilitate a screening. The School Nurse should receive appropriate
training in the use of the equipment as a screening tool and follow
recommended guidelines for appropriate screening frequencies, decibels,
referral criteria, etc.
C. Screening Failure Criteria
1. Failure to respond at the recommended screening level at any frequency
in either
ear constitutes failure.
2. All failures should be re-screened within the same session. This should be
accomplished by removing and repositioning the earphones and carefully
reinstructing
the student.
3. Any student who fails the initial screening should have a repeat screening
done
within two (2) weeks.
4. Any student failing the initial screening and repeat screening will be
referred for
appropriate follow-up and re-screened the following year.
5. An otoscopic exam should be done for any student who fails the initial and
repeat
screenings. Immediate referral is indicated for signs of otitis, cerumen buildup or
foreign body.
148

IV. Common Mistakes Screeners Make:
A. Not being organized
B. Failure to check student’s health record before screening to note whether
already wears
hearing aid or has medical diagnosis of hearing loss
C. Not knowing how to use the testing equipment
D. Not testing equipment before use
E. Not using a quiet/private area for screenings
F. Not making sure equipment fits correctly
G. Not having child turned away/back to equipment for hearing
H. Not holding hearing tone for sufficient length of time
I. Screening at 20dB, 1000, 2000 and 4000 only
J. Failure to view ear with otoscope following failed hearing screening to rule
out
cerumen, foreign body, or infections
K. Not following up on referrals
L. Thinking that assessment equals intervention
V. Follow-up
A. Record test results on the School Health Record.
Section B - 68 - 6-2005
B. Referral
1. Students under professional care need not be referred, but should be
followed to
encourage continuity of appropriate treatment.
2. Notify parent/guardian that the student has failed the hearing screening
and may
have a hearing loss (see “Sample,” Section B, page 70). They should be
advised
that they might elect to receive a diagnostic audiological and otological (ear
examination by an ENT physician) through their family physician, community
ENT physician, or the Division of Public Health.
C. Should the parent/guardian elect services through the Division of Public
Health:
1. Contact the family physician to obtain permission to refer student to the
clinic.
Treatment services are not involved in this referral.
2. New Castle County: Referrals for Audiologic and Otologic Services should
be
forwarded to Christiana Care ENT Clinic at the following location: Wilmington
hospital, Speech and Hearing Department, 501 West 14th Street, Wilmington,
DE
19801 (428-2286).
3. Kent County: Refer for audiology or A & O services to: Williams State
Service
Center, Hearing Services, Route 13 and River Road, Dover, DE 19901 (7395376).
149

4. Sussex County: Refer for audiology or A & O services to: Sussex County
Health
Unit, Hearing Services, 544 South Bedford Street, Georgetown, DE 19947
(8565213).
D. Discuss suspected or known deviations with the appropriate school
personnel.
NOTE: Nurses are urged to follow-up the hearing of students receiving
private care within a
reasonable period of time or to check with the student or family on what care
was given
so as to insure adequate follow-up of the suspected hearing loss.
VI. Resource
A. The Ear and Hearing, A Guide for School Nurses, National Association of
School
Nurses, Inc. 1998.
Section B - 69 - 6-2005

Hearing Screening
Class Record Form

Teacher Grade Room No. Date
Student's Name 1st Screen 2nd Screen
(Alphabetical) Date Pass Fail Date Pass Fail Comments
1.
2.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.

SUMMARY: No. Screened _______ No. Failed ________
150

Section B - 70 - 6-2005
SAMPLE

DATE: _________________
Dear Parent/Guardian:
Your son/daughter recently failed a hearing screening
and may have a hearing problem. You may already be aware of this possible problem and
are taking steps to correct
it. If not, a medical examination is recommended. Please contact me to discuss the
suspected problem.
Many hearing losses today may be corrected before they become serious. While some
individuals have a temporary
hearing loss during a cold or other infection, it is important that the cause of such a
temporary loss be determined and
treated to protect the individual's future hearing.
Nurse
School

---------------------------------------------------------------------------------------------------EXAMINING PHYSICIAN
(Please complete and return to the school nurse.)
Name____________________________ School_____________________ Grade________
Diagnosis
State Treatment Complete
Additional Medical Recommendations:
Prognosis: Stationary _____ Will improve _____ Progressive _____ Intermittent _____
Educational Recommendations:
Do you advise any of the following educational recommendations for the student?
Speech reading _____ Auditory Training _____ Use of hearing aid or amplifier _____
Date of Examination:______________ Examiner______________ M.D.______________
Date of Return Visit: ____________________
NOTE: Please complete and return to the school nurse. Thank you.
Address
Fax

Section B - 71 - 6-2005
Postural & Gait Screening
I. Preparation
A. Obtain class roster to use as work sheet and to record results of screening.
B. Notify parents, students and faculty of upcoming screening. Include
information on
rationale for screening and procedure.
C. Boys should be dressed in shorts and sleeveless top; girls should wear
shorts and
sleeveless blouse or one that opens in the back. This allows for adequate
examination
of head, arms, back, legs and feet.
D. Make arrangements to complete screenings by December 15.
II. Procedure
A. Examination should be done in this sequence:
1. Student walks toward examiner, look for:
a. Symmetry of the body
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b. Abnormality of gait (limp, waddle, feet turn in or out excessively)
2. With student standing in front of examiner, look for:
a. Limitation of neck motion
b. Limitation of arm motion
c. Shoulder level
d. Eye level
e. Pelvic tilt
f. Short leg
g. Leg and foot abnormalities interfering with gait/comfort
3. With student standing sideways to examiner, look for:
a. Abnormalities of AP posture
4. With student standing with back to the examiner, look for:
a. Curvature of the spine or other abnormalities
(1.) Back straight
(2.) Back bent in Adams position
5. Student walks away from examiner and gait is checked again
B. In addition to the above, look for such things as allergies, suspicious
moles, skin
conditions, excessive scarring from burns, and lop ears. Refer to primary
healthcare
provider for further evaluation.
C. Pain is a cardinal sign for immediate referral.
D. Flat feet should be noted and evaluated by primary healthcare provider,
particularly if
chronic pain is present.
III. Common Mistakes Screeners Make
A. Not being organized
B. Not having a quiet-private area for screenings
C. Scheduling males/females at the same time
D. Failing to check student’s health record before screening to note if child is
followed for
an orthopedic condition or is already scheduled for a re-examination in Phase
II from a
previous year
E. Letting child wear shoes
F. During the Adams Bend test:
1. Overlooking the thoracic area
2. Not looking directly at lumbar spine
3. Forgetting to assure the student does not lock his/her knees
Section B - 72 - 6-2005
4. Allowing the child to bend over too fast, or too far, or with only one knee
bent
G. Referring a child with a dominant side (shoulder) slightly lower than the
other side
(This is normal as long as all other aspects of exam are normal.)
H. Failing to alert parents of Phase II
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I. Not following up on referrals
J. Thinking that assessment equals intervention
IV. Follow-up – Phase I and Phase II
A. Record findings on the School Health Record. If a suspected deviation is
detected,
complete one copy of form on Section B, page 73 for Phase II. Notify the
district
coordinator by December 15 of the number of students to be checked in
Phase II.
B. The District Coordinator or School Nurse Liaison will arrange for Phase II
through the
Supervisor of Health Services, Department of Education.
C. Notify parent of referral to Phase II (sample letter on page 74).
D. If parent/guardian elects to seek private medical care in lieu of Phase II:
1. Obtain name of physician and send one copy of the special form with a
cover letter
2. Check with the student or family within a reasonable time on what care
was given
to insure adequate follow-up
3. Have parent/guardian sign authorization to release information for private
physician, duPont Hospital for children, and Shriners Hospital referrals
E. Discuss suspected or known deviations with appropriate school personnel.
F. After Phase II, notify parent/guardian that a suspected deviation has been
detected.
They should be advised that they should seek further examination through
the family
physician, duPont Hospital for Children, or the Shriners Hospital (1-800-2814050)*.
* Note: Some families may have to check with their primary care physician
before
contacting the duPont Hospital for Children or Shriners Hospital.
V. Resources
A. Postural Screening Guidelines for School Nurses (2004), National
Association of
School Nurses.
Section B - 73 - 6-2005

Postural & Gait Screening

STUDENT'S NAME SCHOOL
SCHOOL EXAMINER DATE OF REFERRAL
1. POSTURE
a) Poor________ (unable to correct)
2. WALKS WITH
a) Limp________ (unknown cause)
b) Unusual Gait________
c) Feet turned in ________ (problem of tripping)
3. UPPER EXTREMITIES
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a) Abnormalities ________ (contractures or lack of ROM - range of motion)
4. SPINE
a) Lateral Curvature (Scoliosis) ________ (all curves)
b) Posterior Curvature (Kyphosis) ________ (cannot correct)
c) Anterior Curvature in lower spine (Lordosis) ________ (cannot reduce)
d) Back pain ________
5. LOWER EXTREMITIES
a) Hip problem ________ (Pain, lack of ROM)
b) Knee problem ________ (Pain, lack of ROM, unstable knee)
c) One shorter
6. FEET
a) Any conditions causing pain, excessive shoe wear and/or other problems
7. MUSCULATURE
a) Generalized weakness ________ (overall poor muscle tone, cannot keep
up with peers)
b) Apparent weakness _________ (one or more extremities)
8. REMARKS (Explanation of above, if desired, or any other unlisted abnormalities)
FINAL SCREENING (Phase II)
a) Impression
b) Recommendation

SIGNATURE (Physical Therapist)
Section B - 74 - 6-2005

SAMPLE

DATE: _________________
Dear Parent/Guardian:
A recent postural/gait screening test at school indicates that may
have a postural or gait irregularity which could affect his/her during these
growing years.
The physical therapist will be at this school on to perform Phase II of the
postural
screening. He/she will examine your child to determine if a referral to the
doctor is needed.
Please make every attempt to have your child at school on time this day.
After this exam, you will be notified if the physical therapist feels that your
child needs to have an
additional exam by his/her doctor.
Please call the school nurse with any questions.
School Nurse
Phone
Section B - 75 - 6-2005

VI. Medications
Section B - 76 - 7-2007

817 Administration of Medications and Treatments
1.0 Administration of Medications and Treatment
1.1 Medications, in their original container, and treatments may be administered to a public
school

154

student by the school nurse when a written request to administer the medication or
treatment is on
file from the parent, guardian or Relative Caregiver or the student if 18 years or older, or an
unaccompanied homeless youth (as defined by 42 USC 11434a). The school nurse shall
check the
student health records and history for contra indications and all allergies, especially to the
medications, and shall provide immediate medical attention if an allergic reaction is
observed or
make a referral if symptoms or conditions persist. The school nurse shall also document the
student's name, the name of medication and treatment administered, the date and time it
was
administered and the dosage if medication was administered.
2.0 Licensed Health Care Provider
2.1 Any prescribed medication administered to a student, in addition to the requirements in
1.0, shall
be prescribed by a licensed health care provider. Treatment, including specialized health
procedures, shall be signed by a licensed health care provider with directions relative to
administration or supervision.
3.0 Prescription Medications
3.1 Prescription medication shall be properly labeled with the student's name; the licensed
health care
provider's name; the name of the medication; the dosage; how and when it is to be
administered;
the name and phone number of the pharmacy and the current date of the prescription. The
medication shall be in a container which meets United States Pharmacopoeia National
Formulary
standards.
3.2 Medications and dosages administered by the school nurse shall be limited to those
recommended
by the Federal Drug Administration (FDA), peer review journal that indicates doses or
guidelines
that are both safe and effective or guidelines that are specified in regional or national
guidelines.
3.2.1 The prescription and the medication shall be current and long term prescriptions shall
be re
authorized at least once a year.
3.2.2 All medications classified as controlled substances shall be counted and reconciled
each
month by the school nurse and kept under double lock. Such medications should be
transported
to and from school by an adult.
4.0 Non Prescription Medications
4.1 Non prescription medications may be given by the school nurse after the nurse assesses
the
complaint and the symptoms to determine if other interventions can be used before
medication is
administered and if all requirements in 1.0 have been met.
5.0 IEP Team
5.1 For a student who requires significant medical or nursing interventions, the Individual
Education
Program (IEP) team shall include the school nurse.
6.0 Assistance With Medications on Field Trips
6.1 Definitions
"Assist a Student with Medication" means assisting a student in the self administration of a
medication, provided that the medication is in a properly labeled container as hereinafter

155

provided.
Assistance may include holding the medication container for the student, assisting with the
opening of the container, and assisting the student in self administering the medication. Lay
assistants shall not assist with injections. The one exception is with emergency medications
where
standard emergency procedures prevail in lifesaving circumstances.
"Field Trip" means any off campus, school sponsored activity.
"Medication" means a drug taken orally, by inhalation, or applied topically, and which is
either
prescribed for a student by a physician or is an over the counter drug which a parent,
guardian or
Relative Caregiver has authorized a student to use.
"Paraeducator" mean teaching assistants or aides.
6.2 Teachers, administrators and paraeducator employed by a student's local school district
are
authorized to assist a student with medication on a field trip subject to the following
provisions:
6.2.1 Assistance with medication shall not be provided without the prior written request or
consent of a parent, guardian or Relative Caregiver (or the student if 18 years or older, or an
unaccompanied homeless youth (as defined by 42 USC 11434a). Said written request or

Section B - 77 - 7-2007
consent shall contain clear instructions including: the student's name; the name of the
medication; the dose; the time of administration; and the method of administration. At least
one copy of said written request or consent shall be in the possession of the person assisting
a
student with medication on a field trip.
6.2.2 The prescribed medication, in addition to the requirements in 1.0, shall be prescribed
by a
licensed health care provider. The medication shall be properly labeled with the student’s
name; the licensed health care provider's name; the name of the medication; the dosage;
how
and when it is to be administered; the name and phone number of the pharmacy and the
current date of the prescription. The medication shall be in a container which meets United
States Pharmacopoeia National Formulary standards.
6.2.3 A registered nurse employed by the school district in which the student is enrolled
shall
determine which teachers, administrators and paraeducators are qualified to safely assist a
student with medication. In order to be qualified, each such person shall complete a Board of
Nursing approved training course developed by the Delaware Department of Education,
pursuant to 24 Del.C. §1921. Said nurse shall complete instructor training as designated by
the Department of Education and shall submit a list of successful staff participants to the
Department of Education. No person shall assist a student with medication without written
acknowledgment that he/she has completed the course and that he/she understands the
same,
and will abide by the safe practices and procedures set forth therein.
6.2.4 Each school district shall maintain a record of all students receiving assistance with
medication pursuant to this regulation. Said record shall contain the student's name, the
name
of the medication, the dose, the time of administration, the method of administration, and
the
name of the person assisting.
6.2.5 Except for a school nurse, no employee of a school district shall be compelled to assist
a
student with medication. Nothing contained herein shall be interpreted to otherwise relieve a
school district of its obligation to staff schools with certified school nurses.

156

NON REGULATORY NOTE: 14 DE Admin. Code 612, Possession, Use and Distribution
of Drugs and Alcohol addresses student self administration of a prescribed asthmatic quick
relief inhaler and student self administration of prescribed autoinjectable epinephrine.

Section B - 78 - 6-2005
Recommended Procedures to Follow for Controlled Substances
• Controlled substance medications should be brought to school by a responsible adult
member of the
student’s family and given to the school nurse in the original container.
• If it creates a hardship for the family to deliver the medication, it is the parent/guardian’s
responsibility to
count the number of pills or capsules sent to the school and to verify this with the school
nurse.
• The controlled substance medication is to be counted on arrival by the school nurse in the
presence of an
adult family member, if possible. In the event that the parent/guardian did not deliver the
medication, a
copy of this account should be sent to the parent/guardian who should contact the school
nurse if there are
questions. A copy of the communication sent to the parent/guardian should be kept on file.
• All controlled substances are to be kept under double lock. (The storage cabinet plus
locked room should
be sufficient.) Only authorized licensed personnel should have access to the area.
• Documentation will show the student’s name, time, date of administration and dosage*.
• All controlled substances will be counted and reconciled at least once a month.
• When controlled substances are sent home (end of school year, etc.), the school nurse will
give the
medication to a responsible family member after a count is verified and signed by both the
school nurse and
the adult. If it presents a hardship for a family member to pick up the medication, the school
nurse will
verify numbers with an adult staff person and inform the parent/guardian of the number of
pills/capsules
that are being sent home.
Reviewed by the State Board of Education on 10/17/96.
* Change 3/05.

Section B - 79 - 6-2005
Parental Request to Have Prescription Medication/Treatment
Administered in School
If it is necessary for your child to receive medication during the school day, please do the
following:
• Send the medication to school with a responsible individual if you are unable to take it to
school.
• Send the medication in the original container properly labeled with correct name, time,
dose and
date.
• Count the tablets (unless the number of tablets is the exact number on the label) or
approximate
amount of liquid in the bottle.
• Fill out the following information:
Date
Student’s Name
Medication
Dose Time
Reason for Medication

157

Allergies to any medications
Number of tablets sent
Amount of liquid
I am aware that the school nurse may have need to contact the prescribing healthcare
provider or pharmacist relative
to the medication/treatment and I give my permission.
Parent/Guardian Signature
Nurse’s Signature
Number of tablets/amount of liquid received

Section B - 80 - 6-2005
Information on Controlled Substances
General Information - To determine if a drug is a controlled substance, check the PDR
(Physician’s Desk Reference)
which will indicate whether or not the drug is controlled and the schedule under which is
located.
Some examples are:
Brand Name
Generic Name
Schedule
Title I6
Section #
Opium or Derivative
Narcotics
* Codeine Codeine II 4716(b) (1)
Morphine Morphine II 4716(b) (1)
Percodan, Tylox Oxycodone II 4716(b) (1)
Tussionex, Hycodan Hydrocodone III 4718(e) (4)
Opium Tincture Opium Tincture III 4718(e) (7)
Paregoric Camphorated Tincture of
Opium
III
4718(e) (7)
Dilaudid Hydromorphone II 4716(b) (1)
Barbiturates (Non-Narcotic)
Fiorinal Butalbital III 4718(c) (1)
Phenobarbital Phenobarbital IV 4720(b) (11)
Seconal Secobarbital II 4716(e) (3)
Nembutal Pentobarbital II 4716(e) (4)
Non-Narcotic Stimulants
Ritalin Methylphenidate II 4716(d) (4)
Preludin Phenmetrazine II 4716(d) (2)
Tenuate, Tepanil Diethylpropion IV 4720(h) (1)
Voranil Clortermine III 4718(g)
Sanorex Mazindol IV 4720(j)
Didrex Benzphetamine III 4718(h)
Pleoine, Prelu-2,
Bontril
Phendimetrazine
III
4718(j)
Adipex, Fastin Phentermine IV 4720(f)
Non-Narcotic Tranquilizers and
Depressants
Talwin Pentazocine IV 4720(g)
Librium Chlordiazepoxide IV 4720(b) (12)

158

Valium Diazapam IV 4720(b) (13)
Xanax Alprazolam IV 4720(b) (23)
* Various Codeine combinations with non-controlled drugs may be either a schedule III
4718(e) (1) or (2) or
Schedule V 4722(b) (1) substance depending on the quantity of Codeine therein. Check your
“PDR” or call the
Office of Narcotics and Dangerous Drugs (302) 739-4798.

Section B - 81 - 6-2005

SAMPLE

LETTER TO PARENTS/GUARDIANS ABOUT
NONPRESCRIPTION MEDICATIONS
School nurses may give nonprescription medications with parental permission. The following
guidelines need to be
followed:
1. The school nurse must assess the child's complaint and symptoms to determine if other
measures
can be used before medication is given.
2. The school nurse must be notified of any allergies, especially to medication, that your
child has.
3. All medications sent to the school must be in the original container. (This is the law.)
4. A record of the medication given will be kept by the school nurse.
5. Nurses must use restraint at all times in the use of nonprescription medicines.
Please contact the school nurse, ________________________________________, if you have any
questions.
Nurse Name and Phone Number
----------------------------------------------------------------------------I have read the above and request to give
Name of Nurse
to
Name of Nonprescription Drug Name of Student
on for the following reason:
List known allergies to medicine
Signature of Parent or Guardian
Date

Section B - 82 - 6-2005

Medication Error Report

A medication error is the failure to administer a prescribed medication within
the appropriate
time frame, in the correct dosage, in accordance with accepted practice
and/or to the correct
student.
Date of report School
Student’s name DOB Sex Grade
Home address
Home telephone
Date error occurred Time noted
Person administering medication
Licensed prescriber (name and address)
Reason medication was prescribed
Date of order Instructions for administration
159

Medication Dose Route Scheduled time
Describe the error and how it occurred (use reverse side if necessary):
Action taken PRN
Licensed prescriber notified: Yes _ No _ Date Time
Parent/Guardian notified: Yes _ No _ Date Time
Other person(s) notified:
Yes _ No _ Date Time
Outcome:
Name (type or print) Signature
Title Date
Board of Nursing Approval – 5/10/00

Section B - 83 - 6-2005
Assistance with Medication
Information for School Staff
(For Field Trips
_

Only)
When assisting with medications, it is expected that assistance will be given in a manner
which protects the
student from harm. It is expected both from a legal and ethical standpoint that you will not
knowingly
participate in practices which are outside your legally permissible role or which may
endanger the well
being of the student.
Medication is given to the right student, at the right time, in the right amount (dose), and by
the right route
(such as orally, topically, by inhalation). The following information is developed around these
FIVE
RIGHTS:
• AT THE RIGHT TIME
• THE RIGHT STUDENT
• THE RIGHT MEDICATION
• AT THE RIGHT DOSE
• BY THE RIGHT ROUTE
• THE RIGHT TIME
Routine medications are taken at established times. This helps to insure that the desired
levels of
medication will be maintained and doses will not be given dangerously close to each other.
Medications may be given ½ hour before or after the indicated time except for medications
to be
given with meals. These may be medications which must be given with food.
Some medications should not be given at the same time or in combination with other
medications.
If two or more practitioners prescribe medications, the person assisting must check
medication
compatibility with the nurse, pharmacist, or poison control center.
• THE RIGHT STUDENT
Unlike acute care medical facilities, most schools and other institutions do not require
personal
identification tags. This presents a problem in assisting with medications as levels of
communication and cooperation vary. Even a student may answer to another student’s
name.

160

Basic rules are:
a. Never assist with medication unless you know the student.
b. Use the student’s name during the assistance process.
c. Only deal with one student at a time to prevent other students from interfering with the
medication process.
d. Pre-fill water cups to avoid distractions; do not ever turn away from the student during the
medication process.
• THE RIGHT MEDICATION
Before leaving on the field trip, check the parent/guardian’s permission slip and the
prescription
bottle to be sure the correct medication was sent. For this reason it would be a good practice
to
have all medication on the day before the field trip.
Pill bottles should contain one drug and one drug only. If a prescription is received which
appears
strange and unlike what you remember seeing before, check with the school nurse. It may
be
another drug company’s product, a generic drug or a mistake. NEVER mix the contents of an
old
_ A field trip is an “off-campus, school-sponsored activity.”
Board of Nursing Approval – 5/10/00

Section B - 84 - 6-2005
pill bottle with the contents of a new pill bottle; there may be a change in the brand or dose
which
will create confusion and error.
Read the prescription label and check against the medication log sheet.
• THE RIGHT DOSE
All medications, including over-the-counter (OTC) products, are given in some measured
amount.
Common measurement terms and their abbreviations for tablets, pills and capsules are
milligrams
(mg or mgm), grams (GM) and grains (gr). The prescription will indicate how many pills have
to
be given so you will not need to figure out the number of milligrams. For example, the
prescription
may read: “Tegretol 200 mg tablets; give two tablets daily.” You would give two tablets. The
actual milligram dosage is 400 mg daily but you are not asked to compute this, only to
comply with
the label.
Common measurement terms and their abbreviations for liquids are: ounce (oz), tablespoon
(Tbsp.), and teaspoon (tsp.). Some prescriptions may indicate a measurement in milliliters
(ml).
5 mls = 1 teaspoon; however, teaspoons can vary in size and should not be used routinely.
Liquid
medication measuring cups/containers are available and should be used.
Ear and eye liquids are usually measured in drops (gtt or gtts) or droppers full. Droppers
should be
included in the medication package.
Prescriptions will state the specific amount of medication to be measured out. If confused
about a
measurement, DO NOT GIVE until you have checked with the parent/guardian or school
nurse or
the pharmacist. Follow the practitioner’s orders carefully.
When assisting with medications, you are legally responsible for making sure that you
comply with

161

the requirements that medications be in original containers.
• THE RIGHT ROUTE
Lay assistants are not to assist with injections. The one exception is in use of the lifesaving
medications, where standard emergency procedures prevail in lifesaving circumstances. The
teacher, guidance counselor or administrator should be informed about the medication
instructions.
For your information, the routes appropriate for lay assistance are:
a. oral b. topical c. inhalants
Generally oral, inhalant, and topical medications will be considered for field trip purposes.
a. ORAL: (by mouth)
Types of oral medications are:
(1) Tablets: Pressed powders which are usually acted upon in the stomach. You may crush
between two spoons and unless otherwise indicated, mix with a small amount of food
such as pudding if client has difficulty swallowing. You must make sure he/she
swallows everything.
(2) Capsules/Caplets: Gelatin coated powders or tiny time released beads as in spansules.
Caplets are replacing many capsules in over-the-counter products as caplets resist
tampering. Caplets have the medication in a very highly compressed form with the
outer covering resisting digestion until the intestines are reached. These should not be
crushed or mixed with food.
(3) Enteric Coated Tablets: These have a hard often colored coat on them (similar to the
M&M candies). This is to prevent them from releasing the medication too soon in the
GI tract and causing irritation. DO NOT CRUSH.
Board of Nursing Approval – 5/10/00

Section B - 85 - 6-2005
(4) Liquids: Pour liquids away from the labeled side to keep the label legible. Two types
of oral liquids exist for our purposes: liquids with a short shelf life, and liquids with a
long shelf life.
(a) Short shelf life: Most prescription antibiotics have a short shelf life and
frequently have to be either refrigerated or kept away from heat and out of direct
sunlight. They should be used completely and the container discarded. The
printed expiration date on these bottles indicates the life of the DRY medication.
The pharmacy label gives the date when the mixed solution will expire. DO
NOT USE BEYOND THE PHARMACIST’S LABEL OF EXPIRATION
DATE.
(b) Long shelf life. Most OTC liquids have a long shelf life. The label expiration
date should be checked periodically to insure freshness.
b. TOPICAL: Medications which are applied to surfaces (skin, eyes, ear canals)
(1) Topical skin/hair medications may be creams, liquids, powders, soaps, shampoos,
ointments.
(a) Wear gloves when assisting with topical medications.
(b) Never dip anything (for example a Q-tip) into the medication. Pour (or with a
clean spoon) dip out just enough of the medication for one application into a
clean container and use from there. Never put unused medication back into its
original container.
(c) Ointment in a tube can be squeezed onto a sterile gauze pad or a bandage.
(d) Avoid splashing facial medications into eyes; they can be very irritating.
(e) Do not share tubes of ointment or liquid medications between students to avoid
spreading infections.
c. INHALANTS:
(2) Nasal Inhalants: Follow the directions on the package insert exactly. DO NOT place
the tip of the inhaler deeply into the nose, place the inhaler tip just at the opening of the
nose.
(3) Oral Inhalants such as mist asthma inhalants: Follow the directions on the package
insert exactly. Be very aware of discard dates on these medications as they MUST be

162

discarded and replaced promptly.
QUICK CHECK
Wash your hands before and after assisting a student.
Identify the right student.
Read the parent/guardian’s request and medication label.
STOP and obtain guidance if you have any questions.
Follow medication instructions.
Record medication assistance to the student on the medication sheet.
Report observations.
ERRORS
Errors do occur despite training and precautions. For the student’s safety, errors should be
reported
immediately upon discovery. 911, the Poison Control Center, practitioner, parent/guardian or
school nurse
should be contacted depending upon the nature of the error. All cases of errors reported by
the person
assisting will be kept on file by the school nurse.
RESPONSES TO MEDICATIONS
Board of Nursing Approval – 5/10/00

Section B - 86 - 6-2005
For the safety of the student, the first dose of any medication should be given under the
supervision of the
parent/guardian or school nurse.
a. DESIRED: good response, mission accomplished, the medication bringing desired results
b. NO RESPONSE: medication does not seem to be working
c. ADVERSE REACTIONS: (This is to alert you to potential difficulties, even though no
problems have been documented on field trips.)
(1) ALLERGY: medication causes rashes (sometimes with itching), hives, fatal shock. An
allergy can occur several days after a student has been on a medication or from a
medication the client has had many times before. IF THE STUDENT IS HAVING
TROUBLE BREATHING, CALL “911”; otherwise, call the healthcare provider and
parent/guardian.
(2) UNTOWARD REACTION: This means the effect of the medication is the opposite of
what is expected and desired. Examples are: giving an antihistamine for a cough but
having the student become behaviorally out of control or giving a medication to control
nausea but vomiting occurs instead. Treat as you would an illness that develops on a
field trip.
(3) SIDE EFFECTS: These are undesirable but known reactions to the medication. Report
observations to the parent/guardian and school nurse.
RESOURCES ON DRUG INFORMATION
It is the responsibility of every individual who assists with medication to review possible side
effects of the
medication being given. Information on medication side effects should be available as part
of the
medication log.
For over-the-counter (OTC) medications, the information concerning how to use the
medication and how to
properly store it is printed on the package or bottle. Also, any pharmacist can provide
answers to questions
on use and storage.
a. For prescription medications, the following resources are available concerning how to use
the medication and how to properly store it:
(1) The container label will give directions for use including whether it should be taken
with or without food. If a drug must be refrigerated or has to have special handling, the
pharmacist indicates that on the container.

163

(2) The pharmacy listed on the container can be called if information is needed concerning
use and storage.
(3) The person’s practitioner listed on the container can be contacted for information in
accordance with school policy.
b. Written information references about medications are available upon request from the
following sources:
(1) The pharmacy: Upon request a package insert from particular medications can be
provided. Usually the insert will describe the drug, its intended use, side effects which
can occur with use, side effects which warrant immediate medical consultation,
warnings about individuals who should not be using the drug, and any special handling
or storage directions as appropriate.
(2) The insert is available for prescription medications. Similar information can be found
on the packaging of over-the-counter medications.
MEDICATION STORAGE AND SAFETY
Medication storage and safety indicate a two fold obligation:
a. Medication must be carried in such a manner as to protect it from being accessed by
unauthorized persons – a situation which could lead to misuse/abuse. Medications taken on a
Board of Nursing Approval – 5/10/00

Section B - 87 - 6-2005
field trip should be in the personal possession of the person assisting with the medication
and
secure from unauthorized use.
b. Medication must be carried in a manner that protects the product from deterioration or
container breakage.
(1) Medications which need refrigeration or storage away from light should be
appropriately labeled by the pharmacy and stored accordingly. If medication needs to
be refrigerated, it should be carried in a cooler.
(2) Medications MUST be stored in their original containers. Should an adaptation of a
container be needed, it MUST be obtained from a pharmacist and it must bear the
appropriate pharmacy label. This includes over the counter medications. No
medication may be stored in a container other than the original container. Only a
pharmacist or practitioner can generate a container other than that in which the
medication was originally distributed from the manufacturer.
DISPOSAL OF MEDICATION CONTAINERS
Medication containers should be returned to the parent/guardian or the school nurse.
MEDICATION RECORDS
Records pertaining to medication use include: parent/guardian’s written permission, the
pharmacy label
(original container label), and any other records such as a medication log sheet which are
required by your
school.
The medication log sheet is a record sheet which you initial/sign after each student has
received the
appropriate medication. (A signature sheet identifying the initials must be included on the
sheet.)
The log sheet must show the student’s name, name of the medication, dose, route of
administration, and
time received by the student.
Example: John Doe – ampicillin 250 mg by mouth at 1:00 p.m.
The log should be returned to the school nurse and attached to the regular daily log.
For the reader’s information: Controlled substances must be counted and accounted for to
conform
with federal law, state law, and school policy. Ritalin is a controlled substance.
Errors in recording medication information should be handled according to school policy.

164

24 Delaware Code Section 1921 (a) (16) allows for assistance in self administering
medication during
school field trips upon completion of a training course. The law does not guarantee that one
will not be held
liable, and thereby protected from litigation. There are no such guarantees despite the fact
that
parents/guardians must sign a statement that they “… fully and completely waive any claim
for liability that
may exist against any staff member, resulting from the assistance with medication to my
child.”
Board of Nursing Approval – 5/10/00

Section B - 88 - 6-2005
SIGN-OFF SHEET
SCHOOL EMPLOYEE “MEDICATION ON FIELD TRIP”_ INFORMATION
I received, read, and understand the medication information in the
“Assistance with Medication Information for School Staff.”
I will abide by the safe practices and procedures set forth therein. I am aware that
any questions
regarding this information or the medication should be discussed with the School
Nurse.

Date Information
Printed Name of School Employee Signature of School Employee Received
and Read

Signature of Staff Instructor:
_

A field trip is an “off-campus, school-sponsored activity.”

Board of Nursing Approval – 5/10/00
Section B - 89 - 6-2005

SAMPLE
Parent/Guardian Permission to Assist with Medication to Student
on Field Trip
I give permission for to go on
(Student’s Name) (Specify field trip)
on . I understand a staff member will assist my child with
(date)
medication. Information about the medication that needs to be taken by
(Student’s
is as follows:
Name)
Name of medication
Dose (amount to be taken)
Time to be taken
How it is taken
I understand I must send the medication in the original container.
All of the above information is on the label on the container prepared by the
pharmacist as prescribed by
(Doctor’s Name)
The following are any allergies or health conditions my child has:
Date Parent/Guardian Signature
165

Please contact your school nurse if you have any questions.
School District
Board of Nursing Approval – 5/10/00
Section B - 90 - 6-2005
District SAMPLE
Field Trip Medication Record*
Trip School Date
Student’s Name Medication Dose
Amount Given
Route:
By mouth or
inhalation, etc.
Time Assisted by
* To be kept in the school nurse’s office.
Section C - 1 - 2-2006

Section C.
Illnesses & Injuries:
Acute & Chronic

I. Communicable Disease Control
II. Acute Conditions
III. Chronic Conditions
The information in Section C is intended to assist the school nurse with general
information on
chronic and acute conditions that are frequently seen in the school setting. Just as a
pediatric
nursing text describes techniques and procedures of nursing care within the scope
of practice of
nursing, this manual provides guidelines for school nursing practice. This
information is not,
and should not, be considered as Standing Orders or protocols. Each child is an
individual with
unique strengths and needs and thus it is essential that individualized interventions
be provided
through the direction and collaboration of the primary healthcare provider, the
primary
caregiver and the student.

Section C - 2 - 02-2006

Illnesses and Injuries
Introduction
The role of the school nurse is a diverse one. Perhaps most visible is giving
immediate care in
case of injury or illness; but his/her responsibilities also extend to notifying the
primary caregiver,

166

getting students home or to some other place of safety, and for guiding families,
when necessary,
to sources of treatment.
Care of the Sick and Injured
School nurses should use the nursing process to assess clients and limit themselves
to the usual
and accepted practices of first aid in managing emergencies due to sickness or
accident unless
provided with Standing Orders or with client-specific protocols from a licensed
healthcare
provider. Student emergency plans should be current and easily accessible.
Exclusion of Student
The decision to exclude a child from the classroom or any school activity is based
upon the
individual needs of the child and the risk for the school population to communicable
disease
exposure. The school nurse must make a nursing judgment relative to the
presenting symptoms,
health history and known diagnosis of the child in order to determine if exclusion, a
referral to a
healthcare provider or other appropriate intervention is needed.
Notifying Parent/Guardian/ Relative Caregiver
The student’s primary caregiver should be notified of any serious accident, illness or
necessary
exclusion as promptly as possible. To facilitate this, data should be secured early in
the school
year from the family and kept current on the emergency card, which should be
maintained in the
health room for easy accessibility. The school nurse should contact the
parent/guardian/Relative
Caregiver to coordinate who will pick up the child and assume responsibility for
his/her care. If
neither the parent/guardian/Relative Caregiver nor the emergency contacts are
available, the
child’s healthcare provider may be contacted. The decision for moving and securing
medical aid
defaults to school officials. The first consideration must always be the welfare of the
student.
Role of the School Nurse
The school nurse provides direct care to students and staff who present with
symptoms of illness
or injury. Using the nursing process, the school nurse gives timely, appropriate
nursing
assessment and first aid as necessary and within the scope of school nursing
practice. Referral to
other healthcare providers is provided as necessary. The school nurse is responsible
for the
administration of medications and treatments as prescribed by a licensed
healthcare provider for
the treatment of illness or injury.
167

The school nurse communicates with those responsible for the client’s well-being
regarding the
need for ongoing observation, evaluation, or referral to other healthcare
professionals.
Appropriate confidentiality is maintained for the protection of the client.
Individualized
documentation of the illness or injury is accomplished in a retrievable manner using
standardized
language or recognized terminology (National Association of School Nurses [NASN],
2005).

Section C - 4 - 02-2006

The school nurse coordinates care delivery by creating and implementing individual
health care
plans as appropriate.
The school nurse reviews data regarding patterns of illness or injury for safety or
disease issues.
Proper hand washing and healthy lifestyle choices are taught and encouraged
throughout the
school. Administrators are informed of unusual patterns or severity of occurrences.
The school
nurse reports to proper authorities if abuse is suspected.
References
NASN, 2002. Issue Brief: School Health Services Role in Health Care. Scarborough,
Maine.
NASN and ANA, 2005. School Nursing: Scope and Standards of Practice. Nurse
Books,
Washington, DC.

Section C - 4 - 02-2006
REFERRAL TO THE SCHOOL NURSE Page 1 of 2
Although teachers cannot diagnose a child’s condition or recommend medication, they are
many times the
first ones to note that a child is not performing like his/her peers or is having difficulty in the
classroom.
This information is valuable in facilitating the nurse’s assessment and possible referral for
further
evaluation.
The School Nurse values your input and comments. Please complete this form with your
concerns and
return it to the School Nurse. Listed below are some signs of conditions and examples of
behavior that
may provide clues to physical and emotional problems. While none of these are infallible,
none should be
overlooked. Extremes such as constantly disruptive behavior, continual unhappiness,
inability to learn, are
especially significant. Please remember that this information is confidential.
Student Grade/Section
Date Student Achievement: Good Fair Poor
General Appearance
Facial tic
Lethargic, unresponsive
Poor posture
Radical changes in weight
Unusual gait or limp

168

Unclean/unkempt
Very pale or flushed
Very thin or overweight
Ears
Asking to have things repeated
Discharge
Speaking loudly
Turning head to hear
Eyes
Crossed or turned out
Frequent styes
Holding page/book too close
Inflamed, watery
Squint, frown, scowl
Nose and Throat
Chronic cough
Enlarged glands in neck
Frequent colds
Nasal discharge
Persistent mouth breathing
Skin or Scalp
Bald spots
Frequent scratching
Nits on hair
Numerous pimples, blackheads
Patches of very dry skin
Rashes, sores or bruises
Teeth and Mouth
Bad bite
Cracked lips, esp. at corners of mouth
Dental caries
Inflamed or bleeding gums
Irregular teeth
Speech problem, hard to understand
School Performance
Compulsive neatness to the point that
assignments are never completed
Excuses from P.E.
Failure to achieve
Frequent absences
Marked deterioration in work
Poor memory
Poor reasoning
Very careless work
General Behavior
Aggressive, cruel
Always tired
Constant need for attention
Cries easily
Depressed, unhappy
Destructive
Docile, apathetic
Excessive daydreaming, inattentive
Excessive requests to leave classroom
Restless, hyperactive
Temper tantrums
Unusually timid, fearful
Behavior at Play
Breathless after moderate exercise
Difficulty playing with other
Easily fatigued

169

Extremely excitable
Lack of interest
Poor coordination
Very clumsy

See reverse side _

Section C -5 - 02-2006
Page 2 of 2
Brief description of health problem(s):
Signature of Person Referring
Response to referral:
Signature of School Nurse
Date

Section C -6 - 02-2006

I. Communicable Disease Control
Section C -7 - 02-2006

Communicable Disease Control and Prevention
Introduction
So long as the law compels the student to attend school, the school must make a
systematic effort
to protect the student against preventable diseases which might be acquired in
connection with
the school program. General control measures include policies with respect to
exclusion of the
sick student, readmission after illness, and immunizations against diseases. Of
course,
environmental control measures are the responsibility of the school. Specific control
measures
vary for different diseases.
Role of the School Nurse
The school nurse is often the first health professional to notice an increase in a
particular
communicable disease. Individuals in a school population often have a number of
medical
homes making it difficult for a pattern to emerge. The school nurse provides passive
surveillance
and reports findings to the Department of Health according to established
procedures. The public
health role of the school nurse is further accomplished through immunization
monitoring,
tracking, reporting and excluding for non-compliance.
The school nurse notifies any client whose immune system is suppressed or who
has incomplete
immunization due to non-compliance or exemption when a threatening disease is
present in the
school. The school nurse collaborates with agencies as needed under state
guidelines for the
prevention of transmission of disease. The school nurse informs administrators of
communicable
disease in the school and offers professional consultation regarding the need for
communication
170

with parent/guardian/Relative Caregiver on a limited or widespread basis.
The school nurse assures compliance with standard precautions and hand washing.
Health
education regarding hygiene and safe handling is provided informally.
It is the school nurse who excludes students and staff for communicable disease
and allows reentry
after treatment by a licensed healthcare provider or when symptoms no longer
indicate a
threat to others in the school environment. Careful documentation of the nursing
process, using a
retrievable method and standardized or recognized language supports continuity of
care.
Exclusions
Division of Public Health (DPH) regulations allow for the exclusion of students who
have a
communicable disease. Any student with suspicious symptoms should be excluded
pending a
diagnosis. The student should be isolated until released in the custody of the family
or other
accountable person.
Readmissions
The readmission to school of a student having had a communicable disease is
governed by
guidelines in the most recent editions of the Control of Communicable Diseases
Manual, the Red
Book, the student’s healthcare provider and any specific school requirements. DPH
should be

Section C -8 - 02-2006

consulted if questions arise regarding the exclusion or return. The Epidemiology
Program can be
contacted at 302-744-4541.
References
2003 Red Book: Report of the Committee on Infectious Diseases by the American
Academy of
Pediatrics.
American Academy of Pediatrics. (2004). School Health Policy and Practice. Elk
Grove
Village, Illinois.
Control of Communicable Diseases Manual, 18th Edition. (2004).
Delaware Division of Public Health. Regulations for Control of Communicable &
Other Disease
Conditions.
Delaware Division of Public Health. (2005).
http://www.delaware.dhss.gov/dph/healthinfo.html.
Provides health information on eating right, food safety, getting fit, immunizations,
indoor air
quality, stress, tobacco use, HIV/AIDS, cancer, diabetes, hepatitis, lead, rabies, STDs
and
tuberculosis.

171

NASN and ANA. (2005). School Nursing: Scope and Standards of Practice.
Washington, DC:
NurseBooks.Org.

Section C -9 - 02-2006

Standard Precautions
(Previously called Universal Precautions)
Purpose – To insure that all blood body fluids are handled properly.
Those Affected – All school staff should be alerted to dangers of infections from
body fluids.
School nurses, custodians and teachers should be particularly alert to the proper
techniques
in handling and disposal of materials.
Equipment Needed
Soap Disposal Bags Disposable gloves
Water Dust pans Mops
Paper towels Buckets Protective eyewear PRN
Disinfectants - should be one of the following classes:
a. Ethyl or isopropyl alcohol (70%)
b. Phenolic germicidal detergent in a 1% aqueous solution (e.g. Lysol*)
c. Sodium hypochlorite solution (household bleach), 1 part bleach to 10 parts water.
(Example 1-1/2 cups bleach to one (1) gallon of water. Needs to be prepared each
time used.)
(1) Handle carefully, avoid skin contact.
(2) Will corrode metal.
(3) Will discolor materials such as rugs, clothing.
d. Quaternary ammonium germicidal detergent in 2% aqueous solution (e.g.
Triquat*,
Mytar*, or Sage*).
e. Iodophor germicidal detergent with 500ppm available iodine (e.g. Wescodyne*).
*Brand names are used as examples and are not endorsement of products.
Procedures
General
a. Wear disposable gloves before making contact with body fluids.
b. Wear protective eyewear if blood or body fluid may come in contact with
eyes.
c. Discard gloves after each use.
d. Wash hands after handling fluids and contaminated articles, whether or not
gloves are worn.
e. Discard disposal items including tampons, used bandages and dressings in
plastic-lined trash container with lid. Close bags and discard daily.
f. Do not reuse plastic bags.
g. Use disposable items to handle blood and body fluids whenever possible.
h. Use paper towels to pick and discard any solid waste materials such as
vomitus or feces.
i. Double-bag soiled clothing and send home with student.
Handwashing
a. Use soap and warm running water. Soap suspends easily removable soil and
microorganisms allowing them to be washed off.
b. Rub hands together for approximately 20 seconds to work up a lather.
c. Scrub between fingers, knuckles, backs of hands, and nails.
172

Section C -10 - 02-2006

d. Rinse hands under warm running water. Running water is necessary to carry
away
debris and dirt.
e. Use paper towels to thoroughly dry hands.
f. Discard paper towels.
Cleaning the Environment
Cleaning is a form of disinfection that renders environmental surfaces safe to use or
handle by removing organic matter, salts and visible soils, all of which interfere with
microbial inactivation. The physical action of scrubbing with detergents and
surfactants and rinsing with water removes large numbers of microorganisms from
surfaces.
Although contaminated surfaces can serve as reservoirs of potential pathogens,
these
surfaces generally are not directly associated with transmission of infections to
either
staff or patients. The transferal of microorganisms from environmental surfaces to
patients is largely via hand contact with the surface. Hand washing is imperative to
minimize the impact of this transfer; however, cleaning and disinfecting
environmental
surfaces as appropriate is fundamental in reducing their potential contribution to
the
incidence of healthcare-associated infections.
Most, if not all, housekeeping surfaces need to be cleaned only with soap and water
or
a detergent/disinfectant depending on the nature of the surface and the type of
contamination. The actual physical removal of microorganisms and soil by wiping or
scrubbing is probably as important, if not more so, than any antimicrobial effect of
the
cleaning agent used. When using a detergent/disinfectant, the manufacturer’s
instructions for appropriate use of the product should be followed
(www.cdc.gov/ncidod/hip/enviro/guide.htm).
For washable surfaces
a. For tables, desks, etc.:
(1) Use ethyl or isopropyl alcohol (70%), Lysol, or household bleach solution of
1 part bleach to 10 parts water, mixed fresh.
1 part bleach
10 parts water
(2) Rinse with water if so directed on disinfectant.
(3) Allow to air dry.
(4) When bleach solution is used, handle carefully.
(a) Gloves should be worn since the solution is irritating to skin.
(b) Avoid applying on metal since it will corrode most metals.
b. For Floors:
(1) One of the most readily available and effective disinfectants is the bleach
solution (1-1/2 cups bleach to one [1] gallon water.)
1 part bleach
10 parts water
(2) Use the two bucket system--one bucket to wash the soiled surface and one
bucket to rinse as follows:
173

(a) In bucket #1, dip, wring, mop up vomitus, blood.
(b) Dip, wring and mop once more.
(c) Dip, wring out mop in bucket #1.

Section C -11 - 02-2006

(d) Put mop into bucket #2 (rinse bucket) that has clean disinfectant (such
as Lysol, bleach solution).
(e) Mop or rinse area.
(f) Return mop to bucket #1 to wring out. This keeps the rinse bucket
clean for second spill in the area.
(g) After all spills are cleaned up, proceed with #3.
(3) Soak mop in the disinfectant after use.
(4) Disposable cleaning equipment and water should be placed in toilet or plastic
bag as appropriate.
(5) Rinse non-disposable cleaning equipment (dust pans, buckets) in
disinfectant.
(6) Dispose disinfectant solution down a drainpipe.
(7) Remove gloves, if worn, and discard in appropriate receptacle.
(8) Wash hands thoroughly.
For non-washable surfaces (rugs, upholstery)
a. Apply sanitary absorbing agent, let dry, vacuum.
b. If necessary, use broom and dust pan to remove solid materials.
c. Apply rug or upholstery shampoo as directed. Re-vacuum according to directions
on shampoo.
d. If a sanitizing carpet cleaner (only available by water extraction method is used,
follow the directions on the label).
e. Clean dustpan and broom, if used. Rinse disinfectant solution.
f. Air dry.
g. Wash hands thoroughly.
For soiled washable materials (clothing, towels, etc.)
a. Rinse item under running water using gloved hands if appropriate.
b. Place item in plastic bag and seal it until item is washed.
c. Wash hands as described in #2.
d. Wipe sink with paper towels, discard towels.
e. Wash soiled items separately, washing and drying as usual.
f. If material is bleachable, add 1/2 cup bleach to the wash cycle. Otherwise, add 1/2
cup non-chlorine bleach (Clorox II, Borateem) to the wash cycle.
g. Discard plastic bag.
h. Wash hands thoroughly after handling soiled items.
Special Considerations for the School Setting
Cleaning medical equipment
Manufacturers of medical equipment provide care and maintenance instructions
specific to their equipment. These instructions should also include compatibility with
chemical solutions for cleaning, whether the equipment is water-resistant or can be
safely immersed for cleaning, and how the equipment should be decontaminated if
the
need arises.
Specialized environmental and reusable instrument cleaning
Disinfection and sterilization principles are available at:
http://www.apic.org/AM/Template.cfm?
Section=Search&section=Brochures&template=/C
174

M/ContentDisplay.cfm&ContentFileID=238

Section C -12 - 02-2006

Cleaning nebulizer equipment
Nebulizers are a valuable vehicle to provide an inhaled medication to the respiratory
system thereby improving the quality of the air exchange process and reduce the
severity of the symptoms associated with an asthmatic condition.
Care of the nebulizer medication chamber and mask/mouthpiece
After every use:
• Disconnect nebulizer equipment from air tubing of compressor
• Rinse nebulizer equipment under warm running water for 30 seconds
• Shake off excess water and air-dry equipment thoroughly on a clean towel
• Reassemble equipment and connect to air tubing of compressor. Run compressor
for 10-20 seconds to dry out the inside of nebulizer equipment.
Daily cleaning:
• Clean nebulizer equipment with mild soap and warm water. Rinse completely
with warm water and allow to air dry.
Once a week:
• Disassemble from compressor and air tubing. Clean nebulizer equipment with
mild soap and water. Rinse in hot water.
• Soak for 30 minutes in a solution of 1 part white-distilled vinegar and 2 parts
distilled water. Throw away the solution after use. Do not reuse the solution.
• Rinse with hot water again and allow to air dry.
• To assure dryness, run compressor for 10-20 seconds after reassembly of
equipment.
It is important to keep your nebulizer clean. If it is not clean, the patient may be
breathing in germs that may result in an infection or an asthma attack.
7/2005 Reviewed by DPH Epidemiologist, Paula Eggers, RN.
7/2005 “Cleaning nebulizer equipment” reviewed by Deborah Brown, Director of
Programs &
Advocacy, American Lung Association of Delaware.

Section C -13 - 02-2006

Table 1
Transmission Concerns in the School Setting
Body Fluid Source of Infectious Agents
Body Fluid-Source Organism of Concern Transmission Concern
Blood Hepatitis C Bloodstream inoculation
-cuts/abrasions Hepatitis B. virus through cuts and
-nosebleeds HIV abrasions on hands
-menses Cytomegalovirus
-contaminated needle and others Direct blood stream
inoculation
*Feces Salmonella bacteria Oral inoculation from
-incontinence Shigella bacteria contaminated hands
Rotavirus
Hepatitis A virus
and others
*Urine Cytomegalovirus Bloodstream, oral and
-incontinence mucus membrane
inoculation from hands
175

*Respiratory Secretions Mononucleosis virus Oral inoculation from
-saliva Common cold virus contaminated hands
-nasal discharge Influenza virus
and others
Hepatitis B virus Bloodstream inoculation
Tuberculin microbacterium through bites
*Vomitus Gastrointestinal Oral inoculation from
viruses, e.g., contaminated hands
(Norwalk agent
Rotavirus)
Semen Hepatitis B Sexual contact
HIV (intercourse)
Gonorrhea
*Possible transmission of HIV is currently thought to be of little concern from these
sources
except in the cases of needle sticks or serious cuts.
7/2005 Reviewed by DPH Epidemiologist, Paula Eggers, RN.

Section C -14 - 02-2006

INTERPRETIVE GUIDELINES FOR INFECTIOUS WASTE*
These guidelines are intended to assist persons who work in situations where they
must make
daily decisions concerning the disposal of medical waste. Items considered noninfectious waste
for disposal purposes may carry a risk of disease transmission in the school setting.
Therefore,
workers are encouraged to use good infection control practices and exercise good
judgment at all
times.
1. The following items should NOT be disposed of as infectious waste:
used gloves, masks, gowns (unless dripping)
dressings, bandages (unless saturated)
disposable temperature probe covers
dental care swabs
Fleets enema containers
clothing, sheets, blankets
2. Sponges, bandages, gauze, paper towels, sanitary pads, tampons, and other
items with
absorbed or dried blood should be placed in double bags like other waste.
3. Containers, including IV tubing and suction canisters, holding more than a few
milliliters of
blood or other body fluids should be carefully poured down a sink drain or toilet. If
this is
not possible, the container should be disposed of as infectious waste.
4. Stool in disposable diapers should be flushed. The remaining diaper need NOT be
disposed
of as infectious waste.
Based on the “Interpretive Guidelines for Infectious Waste,” there will be very little
infectious
waste generated in the school health room with the exception of sharps. By
definition, a sharp is
176

anything capable of inflicting a puncture wound or infection. Examples are needles,
scalpels,
razorblades, pipette tips and other sharp metallic or plastic objects. Such objects
must be
disposed of properly to prevent injury. School nurses should actively implement safe
disposal
practices that maximize the protection from sharp injuries. These include:
• Sharps must be stored in red plastic labeled boxes and discarded as infectious
waste when the
container is full.
• Sharp containers must be located in the immediate area where sharps are used.
• When disposing of a needle, drop the needle and syringe assembly into the
container.
• Never recap a needle.
• When containers are full, follow the biohazardous waste disposal protocol.
• Any sharp injury must be documented and reported for proper follow-up medical
care.
Medical waste (items 2-4 on Interpretive Guidelines for Infectious Waste) should be
double
bagged in plastic bags and discarded in the trash. Each district should have a waste
disposal plan
and a designated person to arrange for pick up of infectious waste.
*According to Division of Public Health Guidelines
7/2005 Reviewed by DPH Epidemiologist, Paula Eggers, RN.

Section C -15 - 04-2008

SCHOOL NURSE / PUBLIC HEALTH COMMUNICATION
For Disease Surveillance & Possible Communicable Disease Exposure
Final 7-28-2005
Refer to Control of Communicable Diseases Manual, 18th Edition or
School Nursing: Technical Assistance Manual (DOE) Refer questions regarding
this process to Linda C.
Wolfe, DOE, at 735-4290
or Kris Bennett, DPH at 744-4702
Criteria to determine suspicion level:
Suspicious symptomology / syndrome activity noted over and
above baseline norm for school population and season.
*School nurses will determine their normal baseline activity
to determine when/if they should become suspicious.
NO…..
Continue normal health care referrals
& parental contacts
YES….
Collect appropriate information
Internal school communication
as per protocol
Call DPH, Epidemiology:

1-888-295-5156
OR
302-744-4541
177

Epidemiology Branch:
•Analyzes Information
•Makes Recommendations & Conducts Investigation if indicated
•Consults with Northern and Southern
Health Services if indicated
Criteria to determine communicable disease exposure:
Possible student(s) exposure to communicable disease
based on:
Diagnosis, report or symptomology of student/staff within
the building.
If yes to any of the following, notify Epi:
-Confirmed diagnosis of a communicable disease?
-Highly suspicious symptoms w/ diagnosis pending?
-Capacity for direct or indirect transmission?
-Suspicious symptomology or syndrome activity?

Section C -16 - 02-2006

School Nurse
Passive Syndromic Surveillance
Final 7-28-05

Surveillance (active or passive) is an ongoing process that involves the systematic
collection,
analysis, and distribution of information regarding the occurrence of diseases in
defined
populations. In general, surveillance is designed to provide practical and uniform
results in a
timely fashion so that trends can be detected and appropriate interventions
implemented. In this
case, the defined population is that of the student body/staff within a specific school
or district.
Delaware school nurses participate in “passive” surveillance. Passive surveillance
does not
necessitate routine reporting of symptomology or disease conditions. Instead,
reporting only
occurs when unusual symptomology or events occur. For instance, if the school
nurse were to
observe an unusually high number (above normal and expected baseline) of
children presenting
with GI-related illness or influenza-like-illness (especially out of season) during the
course of a
day, week, or several weeks, he/she would report this occurrence to the Delaware
Division of
Public Health, Epidemiology Branch. Hence, it will be necessary for the school nurse
to have a
working knowledge of the baseline of usual and customary illness for his/her school
population.
In the event the school nurse feels the need to call the Epidemiology Branch, he/she
should be
prepared to answer a few questions presented by a member of the Epidemiology
Branch. This
178

information will assist the Epidemiology staff in analyzing the situation and
determining whether
further investigation is necessary. Strict confidentiality of student identifiers will be
maintained
unless public health concerns are compromised. In this case, the matter will be
thoroughly
discussed with school administration. School nurses should continue to follow their
normal
internal communication procedures.
The following is a list of questions the school nurse may be asked by a member of
the
Epidemiology staff. It should be noted that each particular circumstance will warrant
a unique set
of questions and this should only be considered as a general guide.
1) What is the detailed symptomology?
2) Who is affected? (i.e., Confined to a single classroom? Specific grade? Number of cases by
grade?)
3) When were the first symptoms noted?
4) How long have symptoms lasted?
5) How many children are symptomatic?
6) If a single child, are family members symptomatic?
7) If a single child, who are their closest contacts? (Whom do they sit beside in class? Who
are their
closest friends?)
8) Is any school staff symptomatic?
9) Is the illness confined to one classroom? One region of the school? School-wide?
10) Do those presenting with symptomology share a common restroom?
11) Do those presenting with symptomology share common meals?
12) Is the child on any medication?
13) What is the name of the child’s physician?
14) Is the child/ren involved in any extracurricular activities?
15) Did the child/ren become ill after playground activities?
16) Has there been any unusual activity on or around school property?

Section C -17 - 02-2006

Contagious Disease Letter
Dear Parent/Guardian:
It is our school’s goal to provide a safe and healthy learning environment for your
child. It is
very important to limit contagious diseases at our school.
At times, childhood illnesses are not preventable. It has been brought to our
attention that your
child may have been exposed to . Because
your child may have been exposed to this illness, please watch for the signs and
symptoms listed
below:
If your child shows any of these signs and symptoms, please keep your child at
home. Call your
healthcare provider to discuss care for your child. Your child may need to stay home
until the
symptoms are gone or treatment is started. A medical note to return to school is
needed. By
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notifying you of this possible exposure, we are trying to prevent new cases of this
disease.
Thank you for your cooperation.
Sincerely,

Section C -18 - 02-2006

Meningitis Action Plan for Delaware School Nurses
A suspected or confirmed case of meningitis in your school will cause concern
among students,
teachers and families. It is not uncommon for TV, radio and newspapers to follow up
on the
story. The Division of Public Health (DPH) can help you prepare for, confirm and deal
with a
meningitis case. It should be noted that there are different forms of meningitis.
Neisseria
meningitis is highly contagious. Other forms, while serious to the individual, are not
transmissible person-to-person. In the case of Neisseria meningitis, early
identification of close
contacts is critical.
Things to do before a case of meningitis occurs:
1. Identify and contact key experts. The School Nurse Liaison, at least one other
school official
and your area Public Health Nurse (PHN) should be included.
2. Nursing and Epidemiology staff from the Division of Public Health will help draft
two
generic form letters, one for meningococcal (bacterial) and one for viral meningitis.
The
PHN will give you a meningitis fact sheet, which can be distributed with the letter if
the need
arises.
3. Choose a contact person. This person will coordinate activities with Public Health
and other
public officials.
4. Ask administration to identify a school spokesperson in the event media requests
information
or an interview. Include your school’s public information officer.
5. Establish a phone response team. These individuals are responsible for answering
questions
from concerned families and students. You may consider referring these questions
to Public
Health.
6. Choose a spokesperson to reassure the students.
Things to do when a meningitis case occurs:
1. Inform your principal and your meningitis “experts.” Immediately contact the
Public Health
Epidemiology Branch at 302-744-4541.
2. Provide the following information to the Epidemiology Branch staff:
• Child’s name;
• Date of birth;
• Date last attended;
• Grade;
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• Parent/guardian/Relative Caregiver name and phone number;
• If the child is hospitalized, give the hospital name and location.
The DPH Epidemiology Branch will verify the diagnosis and the type of meningitis
(bacterial vs.
viral), then telephone you and your contact person with this information. The
Epidemiology
Branch staff member will also alert the DPH Public Information Officer (PIO). Public
Health
nurses will assure that legitimate contacts receive preventative medications. If a
contact of a
case, but not the case, attends your school, reassure the students that they are not
at risk. Contact
Public Health if you need support.
7/2005 Reviewed by DPH Epidemiologist, Paula Eggers, RN.

Section C -19 - 02-2006

Guidelines for Pediculosis Control
To provide effective management of pediculosis.

Description
Terminology
Pediculosis (head lice) is an infestation of head lice (pediculus capitus) that can
occur on the hair,
eyebrows and eyelashes. Body lice (pediculus corporis) and crab lice (phthirus
pubis) can also
lead to infestation of the clothing and pubic area, respectively (Control of
Communicable
Diseases Manual, 2004).
“There are three forms of lice:
• Nit: Nits are head lice eggs. They are hard to see and are often confused for
dandruff or hair
spray droplets. Nits are found firmly attached to the hair shaft. They are oval and
usually
yellow to white in color. Nits take about 1 week to hatch.
• Nymph: The nit hatches into a baby louse called a nymph. It looks like an adult
head louse,
but is smaller. Nymphs mature into adults about 7 days after hatching. To live, the
nymph
must feed on blood.
• Adult: The adult louse is about the size of a sesame seed, has six legs, and is tan
to grayishwhite.
In persons with dark hair, the adult louse will look darker. Females lay nits; they are
usually larger than males. Adult lice can live up to 30 days on a person’s head. To
live, adult
lice need to feed on blood.” (CDC, 2004)
Biology
The head louse generally inhabits warm areas, preferring the nape of the neck and
behind the
ears. The color of the louse varies with the coloration of the human host. The louse
attaches to
the hairs with hook-like claws located on its six legs.
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The nymph and adult louse feed on human blood by piercing the skin of the scalp,
injecting saliva
to prevent clotting and sucking blood into its digestive tract. Itching, the primary
symptom of
infestation, is caused by the saliva injected prior to this blood sucking.
Communicability
Head lice can be acquired by direct contact with an infected person or indirectly by
contact with
personal items, particularly coats, caps, scarves, combs and brushes; lying on
infested carpets or
beds; resting the head against upholstered furniture that has been used by an
infested person.
Fallen hairs with viable nits attached may contaminate the environment and serve
to transmit the
louse. Lice can survive for a week without a food source.
Those at highest risk include children ages 3-10, their families and females.
Pediculosis is rare
amongst African-Americans in the United States. (CDC, 2004)
Symptoms
Persons infested with lice will present with itching. Additional signs of infestation are
tiny bite
marks on neck and scalp, possible swelling of the cervical and axillary lymphs, and
secondary
bacterial infection due to scratching.

Section C -20 - 02-2006

Preventative Measures
Although lice have existed for over 2000 years, they continue to be common
amongst children
worldwide and elude eradication. “There is no scientific consensus on the best way
to control
head lice infestation in school children.” (NASN, 2004) Best practice indicates the
infestation
can be reduced by minimizing the sharing of personal items (i.e., combs, hats,
bedding, pillows,
etc.), early identification and prompt treatment.
Nursing Assessment and Intervention
Technique for inspection
Part the hair (nape of neck or behind ears) with wooden applicator sticks or gloved
hands. Nits
and crawling forms can be seen with the naked eye or assisted with a magnifying
glass and
illumination. If crawling forms cannot be observed, look for nits – silvery ovals
usually attached
within ¼ inch of the scalp. Nit cases (inactive infestation) remaining once the lice
have hatched
are empty, translucent, and found on hair shafts farther than ¼ inch from scalp. If in
doubt as to
whether the condition represents an active or inactive infestation, remove several
shafts of hair

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with nits attached and examine them under a microscope. Dandruff, debris, and
hair spray drops
can be mistaken for nits. Free-living bugs like aphids may be mistaken for the
crawling forms of
head lice as well.
Referral
Students with active infestation should be excluded from school until treated.
Pharmacists and
physicians can assist in recommending over-the-counter or prescribed topical
medication.
Directions from the treatment labels should be followed exactly regarding
application and any
repeat treatments.
Removal of nits is important in further decreasing the likelihood of re-infestation.
Comb hair
with a fine tooth metal comb to remove nits. Over-the-counter products or hot
vinegar may help
in loosening the nit from the hair shaft.
Prevention of spread or re-infestation
Personal items can be cleaned by any of the following methods:
• Washing in hot water in washing machine
• Putting in hot dryer for 20 minutes
• Dry cleaning
• Storing in a sealed bag for one week
• Boiling combs, brushes, curlers, etc. for 10 minutes
• Soaking in 2% Lysol solution and water for one hour
• Freezing for 48 hours
Thorough vacuuming of carpets, floors and furniture is all that is necessary in the
rest of the
household. Insecticide sprays are not recommended.
Treating head lice
Treating Head Lice, a Fact Sheet prepared by the CDC in 2004, is helpful to families
and nurses.
Role of the School Nurse
“The school nurse is the most knowledgeable professional in the school community
and so ideally
suited to provide education and anticipatory guidance to the school community
regarding “best

Section C -21 - 02-2006

practices” of pediculosis management. The school nurse’s goals are to contain
infestation,
provide appropriate health information for treatment and prevention, prevent
overexposure to
potentially hazardous chemicals, and minimize school absence.” (NASN)
References
Control of Communicable Diseases Manual, 2004. p. 396-397
Lice infestation retrieved at www.cdc.gov/ncidod/dpc/parasites/lice on 7/21/05
Pediculosis in the School Community, Position Statement, NASN, 2004. Retrieved at
www.nasn.org/positions/2004ps.pediculosis.pdf on 7/21/05.

Section C -22 - 02-2006
183

Dear Parent/Guardian:
Your child was sent home today because he/she has head lice. Lice are small insects
which spend
their entire lives living on humans. Having lice is not a sign of poor hygiene habits.
Properly
treated cases are no longer infectious.
How would I know if my child has lice?
Lice cause scalp itching. Look for the lice or their eggs on the hair where the hair
comes out of
the scalp. Lice are small (less than 1/8 inch long), tan-colored insects, alive and
moving. They
prefer the back of the scalp, behind the ears, and above the neck. The eggs (nits)
are gray-white
specks glued to the hair. Eggs more than 1/4 inch out on the hair shaft are generally
dead or
empty. Even if you can't find the insects, lice must be there if the eggs are there.
How could my child get lice?
Lice don't jump or fly and depend on direct person-to-person contact or sharing of
personal items
such as combs, brushes, hats, scarves, jackets, sweaters, sheets, pillow cases,
blankets, etc. to
spread. Your child probably got head lice one of these ways.
How do you get rid of head lice?
You may purchase an over-the-counter, non-prescription product (RID*, A-2000*,
Nix*, or
Pronto*) from the drugstore, or physician-prescribed treatment. Follow the directions
as given on
the bottle. Repeat the treatment in 7 to 10 days to kill any surviving nits.
Clean personal items by any of the following methods:
1. Wash in hot water in washing machine
2. Put in hot dryer for 20 minutes
3. Dry clean
4. Store in a sealed plastic bag for one week
5. Boil combs, brushes, curlers, etc. for 10 minutes
6. Soak in 2% Lysol* and water for one hour
7. Freeze for 48 hours
Thorough vacuuming of carpeting, floors, and furniture is all that is necessary in the
rest of the
household. The insecticide sprays are not recommended.
How do I get the nits off after successful treatment?
Use a fine-tooth metal comb dipped in warm vinegar. It is important all nits be
removed.
REMEMBER: Head lice are not choosy about whom they infest. Anyone can get
them. They
cause no illness, only some inconvenience. The important thing is to treat promptly
and
thoroughly. Your cooperation is essential in preventing the spread of head lice.
If you have any questions, please feel free to call the (school nurse) at
(phone no.) .
Sincerely,
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* Brand names are mentioned for identification purposes and do not constitute
endorsement.

Section C -23 - 02-2006

II. Acute Conditions
Section C -24 - 02-2006

Providing Acute Care in the School Setting
Overview
Integral to providing school health services, is the provision of acute care. While the
primary
client is the student, others may require prompt attention from the school nurse.
These may
include educational staff, contracted personnel, volunteers and visitors. Because the
student is the
primary client, references throughout this section will refer to the client as
“student”; however,
the school nurse should be adept at first aid for clients of all ages and able to
provide lifesaving
measures until Emergency Medical Services (EMS) assumes care. The goal of school
health
services relative to acute care is to return the student to optimal health. The school
nurse assesses
the health status, identifies health needs, triages care, provides appropriate nursing
interventions
to alleviate or stabilize the condition, and returns the student to full activity or
refers him/her for
additional medical evaluation/treatment.
General Guidelines
General principles of first aid and emergency care should be followed. Guidelines
within this text
are commonly recommended interventions, but should be implemented only after
consideration
of each student’s pre-existing medical conditions.
_ Prevention, health promotion, safety precautions and eliminating environmental
hazards
reduce the risk of emergencies. The first consideration is to prevent an injury from
occurring.
_ Emergency Plans from the student’s physician should be available for any student
with a lifethreatening
condition. Plans should be up-to-date and renewed annually (minimally). These
directions take priority over other guidelines.
_ Current (annual) emergency cards must be available for all students (refer to
Section B, page
8). Directions on the cards should be followed. It is also helpful to have emergency
contact
information and medical history on staff members.
_ Crisis Plans should be reviewed and discussed with administrators prior to an
emergency to

185

determine the school’s response to emergencies and the role of the school nurse.
Questions to
be considered:
o Have safety issues been addressed?
o Are emergency supplies adequate?
o Are additional school personnel trained in first aid and/or CPR?
o How (and who) will call 911 to activate EMS? Who will meet EMS responders and
guide them to the student?
o Who will assist the school nurse in the event of an evacuation or mass casualty?
o Does district policy address reporting injuries or illness?
o Under what circumstances does administration want to be notified?
o Are communication systems adequate?
_ Emergency equipment and supplies should be evaluated periodically (minimally at
the
beginning of each school year). These should be up-to-date and in working order.
The
school nurse should be comfortable with their use.
_ Parents/Guardians should be notified of acute, or potentially, acute conditions or
situations.
Information on when (i.e., signs and symptoms) to seek additional medical care
should be
reviewed at that same time.
_ Administration should be notified when 911 is called and for any serious
illness/injury. For
other situations, follow district policy or administrative directives.
_ The school nurse should be familiar with both state and local school/district policy
regarding
emergency procedures, including appropriate state/district documentation after the
incident.

Section C -25 - 02-2006

_ Nursing documentation should include aspects of assessment, interventions,
notifications, and
student responses. Refer to Section B, pages 7, 28-29 for Accident Reports.
Preparing for an Emergency
Health rooms should be equipped with standard emergency and first aid equipment,
in addition to
necessary assessment tools. It is recommended that a “Go Bag” (School Nurse
Emergency Kit) is
easily accessible, transportable and fully stocked for use in a school evacuation or
for carrying to
the site of an emergency. Equipment may include, but is not limited to:
Adrenalin, with syringe and physician order
Ambu Bag, with mask
Bandage scissors
Disposable handwipes
Disposable vinyl gloves
Eye wash for irrigation
Flashlight with batteries
Glucose tablets and/or glucose gel
Gauze pads, sterile, 4” by 4”
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Gauze, roller bandage
Instant ice
Large and regular size band-aids
Large plastic trash bag
Non-stick gauze pads
Note pad/pen
Paper tape, 1”
Permanent marker
Safety glasses or goggles
Safety pins
Sanitary napkins (for pressure dressing)
Sling
Soap
Splint
Spyhgmomenometer
Sterile saline
Stethoscope
Thermal reflective blanket
Thermometer
Tongue blades
Towel
Tweezers
In the event of an emergency evacuation, additional items should be accessible and
easily
transportable:
All student emergency cards
All faculty emergency cards
Cell phone or walkie/talkie
Bottle of water
Plastic cups
Emergency medications

Section C - 26- 07-2007

Recommended Common School Nursing Interventions for Illness
and
Injuries
This segment of the School Nursing: Technical Assistance Manual puts forth
commonly
recommended nursing and first aid interventions for illness and injuries that may
present in the
school health office. Another valuable reference is School Nursing: A Comprehensive
Text
(Selekman, 2006). Multiple texts and a School Nurse Manual Committee (2005)
have been
consulted. The science and best practice for nursing care, emergency medicine and
first aid are
constantly changing to improve outcomes for clients. For the most up-to-date
information,
consult current pediatric emergency texts, first aid manuals and trusted websites. If
in doubt, seek
187

medical consultation from the primary healthcare provider or EMS.
Health education is essential when working with students and families. The websites
marked
with an asterisk (*) below are recognized resources and provide fact sheets that are
helpful.
The following resources were used in development of this portion of the Manual:
Jordan, Kathleen. (2000). Emergency Nursing Core Curriculum. Philadelphia, PA: W.B.
Saunders, Co.
Kolar, K. Fisher, W. and Gordon, V. (2001). Nurse, My Head Hurts: A Review of
Childhood
Headaches. Journal of School Nursing, 17 (3), 120-125.
Michigan Association of School Nurses. (2003). First Aid Emergency Guide.
Selekman, J. (2006). School Nursing: A Comprehensive Text.
Stoy, W.A., Platt, T.E. and Lejune, D.A. (2005). Mosby’s EMT-Basic Textbook, 2nd
Edition. St.
Louis, MO: Elsevier Mosby.
Venes, D. (2005). Taber’s Cyclopedic Medical Dictionary, 20th Edition. Philadelphia,
PA: F.A.
Davis, Co.
Websites (retrieved 11/15/05):
* Centers for Disease Control and Prevention: www.cdc.gov.
* KidsHealth, Nemours Foundation: www.kidshealth.org/parent.
Mayo Clinic for Medical Information and Research: www.mayoclinic.com.
Ohio Chapter American Academy of Pediatrics, Emergency Guidelines for Schools,
2000.
Available at: http://www.emsc.
org/downloads/pdf/emscguide.pdf#search='Ohio%20Chapter%20Emergency
%20Guideli
nes%20for%20Schools Retrieved on 11/15/05.
Stafford, K. (2004). Tick Management Handbook. Center for Disease Prevention and
the
Connecticut Agriculture Experiment Station. Available online at:
http://www.cdc.gov/ncidod/dvbid/lyme/resources/handbook.pdf.
University of Maryland Medical Center, Home Page – First Aid for Minor Emergencies:
http://www.umm.edu/non_trauma/index.htm.
The School Nurse Manual Committee members for 2005 were Linda Blackwell, Jane
Boyd, Janet
Brown, Beth Mattey, Nancy Nadel, Barbara Stapen, Elizabeth Thomas, Bonnie Webb,
Susan
Wiggins and Renate Wiley.

Section C - 27 - 02-2006

Nursing Process

All school nurse assessments should follow the nursing process and include an
ABCD
assessment, both initial and ongoing:
Airway/C-spine immobilization
Breathing
Circulation
Disability (Neurological Status)
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If any of these initial assessments are abnormal, nurses should proceed with
emergency
resuscitation techniques including a c-spine immobilization, if necessary, and CPR.
EMS should
be activated immediately by calling 911. The student’s Emergency Treatment Card
should be
accessed and shared with EMS upon arrival. Once the initial or primary assessment
is complete,
a secondary assessment is necessary using the nursing process. The systematic
collection of data
should include subjective and objective data, diagnosis, plan/intervention and
evaluation of
outcomes.
Subjective
History
Objective
Inspection
Auscultation
Percussion
Palpation
Diagnosis
Plan/Intervention
Outcome and Evaluation
Within the following pages, recommended HIAPePa are provided along with specific
actions.
The most probable interventions are identified using the Nursing Intervention
Classification
(NIC) language; however, specific interventions are determined by the needs of the
student and
others may also be indicated. (Refer to Section B, pages 15-20). In all situations
these NICs
should be considered: Health Education, Health Care Information Exchange, Health
System
Guidance, Referral Management and Telephone Consultation.
The Guidelines for Parent/Guardian/Relative Caregiver (Section C, page 60) may be
helpful in
providing instructions.

Section C - 28- 07-2007

ABDOMINAL PAIN

NIC: Bleeding Reduction: Wound; Bowel Management; Emergency Care (injury); First Aid;
Medication Administration; Pain Management; Rest; Vital Signs Monitoring
NOTE:
Good history taking is essential. There are many conditions related to abdominal pain,
some of which may be life-threatening. Abdominal injury is common in children and
may not be immediately obvious. Chronic or severe pain should be referred for medical
evaluation.
1. HIAPePa
a. During the assessment, consider:
• Appendicitis
• Bowel habit disturbance
• Dehydration

189

• Dysmenorrhea, mittelschmerz
• Emotional distress
• Gastroenteritis
• Heart attack
• Henoch-schlonlein purpura
• Internal injury
• Obstruction
• Pharyngitis
• Pregnancy
• Urinary Track Infection (UTI)
b. Assessment – note:
• Duration and location of pain. Most simple pains are at the center of the abdomen.
• Pain level using the Wong-Baker Faces Pain Rating Scale at
http://www.intelihealth.com/IH/ihtIH/WSIHW000/29721/32087.html#wong or the numeric
scale (0-10 with o being no pain and 10 the worst, unbearable pain)
• Fever, vomiting, or diarrhea and characteristics of emesis and stool
• Groin pain, urine problems, or rash
• When and how much did student last eat? (Spicy foods or foods high in lactose or sorbitol
are
associated with abdominal pain.)
• Ask about relationship of pain to activity, meals, and time of day
o Night pain or pain on awakening suggests peptic origin.
o Pain that occurs in the evening or during dinner can be a feature of constipation.
Constipation is most often left sided or suprapubic.
• Ask about sleep pattern.
• Evaluate absentee record of the student, any stressors.
• If female, does the student have menses?
• What medications does the student take?
c. Red Flags – persistent fevers, involuntary weight loss, deceleration of linear growth, GI
blood
loss, frequent vomiting, arthritis, chronic severe diarrhea, iron deficiency anemia, and
dysuria
2. Nursing Actions
a. Pain associated with injury:
• Maintain ABCDs of emergency care.
• Determine mechanism of injury and provide wound care (refer to Wounds in this section).
• Call 911 for severe and/or persistent pain, rapid or thready pulse, diaphoresis, decreased
level
of consciousness, abdominal muscle guarding, rebound tenderness. Notify parent/guardian
and administration.
• Avoid changing position of the student. Keep him/her warm and comfortable.
• Monitor vital signs.

Section C - 28a- 07-2007
• Keep NPO.
• Notify parent/guardian of any significant abdominal injury.
b. Pain without history of injury:
• Arrange for immediate medical transport if several pain accompanies:
o Post surgery status
o Pregnancy
o Localized area
o Abdominal tenderness to touch, muscle guarding, or rebound tenderness
o Swollen abdomen
o Radiating pain to back, shoulder, and/or chest
o Other abnormal symptoms: fever, vomiting, bloody stools, or difficulty breathing
• If fever, persistent or severe pain, contact parent/guardian and advise medical care.

190

• Keep NPO if severe or persistent pain.
c. Other:
• If acute pain, have student lie down in comfortable position.
• Mental Health Interventions - help student identify stressors that may cause abdominal
pain.
Try relaxation techniques. Refer to school counselor.
• Diet interventions – increase fiber and bran, follow lactose free diet, decrease or avoid
foods
like caffeine and foods high in sorbitol
• Behavior management – encourage parents to restrict activities to schoolwork or bed if
child
can’t go to school. Minimize attention that is paid to the abdominal pain behavior. Reward
the child when he/she participates in normal activities even though he/she has pain. Help
the
child relax and minimize stress in his/her life.
3. Other indications for parent/guardian contact and referral for medical evaluation
• Chronic, severe or persisting pain
• Significant injury at school
4. Future consideration
• Address causes or triggers for chronic pain.
Additional references:
Lake, A.M. (1999). Chronic abdominal pain in childhood: Diagnosis and management.
American Family
Physician, 59(7). http://www.aafp.org/afp/990401ap/1823.html
Leung, A.K.C. & Sigalet, D.L. (2003). Acute abdominal pain in children. American Family
Physician,
67(11), 2321-2326.

AIRWAY OBSTRUCTION
NIC: Airway Management; Airway Suctioning; Artificial Airway Management; Emergency
Care;
Medication Administration; Resuscitation

Section C - 29- 02-2006
NOTE:
_ Any airway obstruction constitutes an emergency and requires prompt intervention.
A thorough history and assessment should follow actions to alleviate the obstruction.
_ School nurses must hold current CPR certification and be able to perform the
Heimlich maneuver.
_ There are a number of conditions which can result in airway obstruction: foreign
body obstruction, anaphylaxis, asthma, respiratory infections, heat/smoke
inhalation, chemical burns from ingestion and trauma.
_ Some children and adolescents engage in choking/suffocation games. Such activities
can lead to permanent brain damage and death. An unconscious child, regardless of
the cause, should receive prompt medical evaluation.
1. HIA
2. Partial obstruction
a. Signs
_ Gasping
_ Stridor
_ Wheezing
_ Intercostal muscle retraction
_ Nasal flaring
_ Respiratory distress and hypoxia
_ Apprehensive or scared facial expression
b. Action
(1) If choking from potential foreign body

191

(a.) Encourage coughing to clear airway.
(b.) Place in sitting position. Do not lie down.
(2) If tracheostomy, follow doctor’s orders regarding suctioning.
(3) If anaphylaxis or asthma, follow doctor’s order regarding STAT medication.
(a.) If anaphylaxis or if symptoms persist, call 911. Notify parent/guardian and
administration.
(4) Other causes require close monitoring and a 911 call or immediate medical attention
depending upon symptom severity.
3. Total airway obstruction
a. Signs
_ Universal choking sign (student grasps front of neck with one hand)
_ Unable to cough or speak
_ Gasping or inability to gasp
_ Inspiratory chest movement with no air movement
_ Inability to talk
_ Diaphoresis and pale
_ Tachycardia
_ Cyanosis (check nail beds, lips and mouth), lethargy and unconsciousness will result
from severe hypoxia
_ Apprehensive or scared facial expression
b. Action
In all situations, call 911. Notify parent/guardian and administration. Continue to monitor
after spontaneous respirations return.
(1) If choking, use Heimlich maneuver.
(a.) After clearing airway, rescue breathing and/or CPR may be needed.
(2) If tracheostomy, follow doctor’s order regarding suctioning.
(3) If anaphylaxis or asthma, follow doctor’s order regarding STAT medication.
(4) In all circumstances, maintain an open airway.
4. Future considerations:

Section C - 30- 02-2006
a. Provide health education on reducing choking risks and train staff/student to perform
Heimlich maneuver.
b. For allergic responses, assist student to identify and avoid allergens.

AMPUTATION FROM TRAUMA OR ACCIDENT

NIC: Bleeding Reduction: Wound; Emergency Care; Hemorrhage Control; Vital Signs
Monitoring
NOTE:
Of special importance is addressing potential life threatening emergencies (i.e., shock,
hemorrhage) that may occur at same time as amputation. ABCDs of emergency care
must be a priority. Continue to reassess throughout care. The student will be
frightened and in extreme pain.
1. HI
2. The first priority is the student. Control bleeding.
a. Apply sterile gauze and direct pressure.
b. Immobilize and slightly elevate the extremity.
c. Do not apply tourniquet.
d. Keep student NPO.
3. Call 911. Notify parent/guardian and administration.
a. If EMS is delayed and it is necessary to clean the stump, use only large amounts of sterile
saline to flush the area.
4. Retrieve the amputated part.
a. Any size part should be retrieved and transported.
b. Gently rinse part with cool water or saline solution.
c. Do not rub or clean with soap, water or antiseptic solution.

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d. Wrap amputated part in sterile gauze soaked in saline solution or water. Part should be
kept
moist, but not soaked.
e. Place part securely in waterproof, plastic bag, and place on ice. It is preferable to double
bag. Do not freeze or allow part to come into contact directly with ice. Do not use dry ice.
The part needs to be kept cool, not frozen, to enhance the prospects of reattachment.
f. Label the bag with the name of the student and body part and transport with the student
to the
hospital.
5. Once bleeding is stabilized, monitor for shock and assess for additional injuries.
6. Future considerations:
a. Observe for signs of infection.
b. Promote wound healing.
c. Provide health education on wound care with student and parent/guardian.
d. Provide emotional support.

ANAPHYLAXIS
NIC: Airway Management; Emergency Care
Anaphylaxis is a life-threatening event that requires immediate medical attention. Public
schools are
provided with annual Standing Orders for the treatment of allergic reactions in undiagnosed
individuals.
Students with known life-threatening allergies should have individual emergency orders and
medication
available.

ASTHMA EPISODE
NIC: Airway Management, Airway Suctioning, Asthma Management, Emergency Care,
Medication
Administration, Vital Signs Monitoring

Section C - 31- 02-2006
Acute and chronic care is addressed in Section C on pages 79-83.

BLEEDING (Severe Bleeding from External Wound)
NIC: Bleeding Reduction: Wound; Emergency Care; Hemorrhage Control; Vital Signs
Monitoring
NOTE:
Bleeding in adults and children occurs at the same rate. Because of body size, blood loss
in children can lead to more serious consequences more quickly.
1. HI
2. Superficial wounds should be treated as abrasion/laceration. (See Wounds,
Abrasions/Lacerations,
page 54-55)
3. Have student lie down with legs slightly elevated.
4. Remove obvious debris, but don’t probe or remove penetrating object.
5. Apply sterile gauze and direct pressure to control bleeding. Larger wounds or those with
more
copious bleeding will require longer and more diffuse pressure. Do not remove original
dressing if
bleeding comes through. Reinforce original dressing with more dressing. (Sanitary pads work
in an
emergency.)
6. Elevate affected extremity.
7. If bleeding is not controlled within minutes, apply pressure points. Do not apply
tourniquet.
8. Immobilize area to prevent further injury.
9. Call 911. Notify parent/guardian and administration.

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10. Maintain ABCDs of emergency care.
11. Check health status for bleeding disorder and for recent tetanus.
12. Future consideration:
a. Monitor for future infection or poor healing.

BLISTER

NIC: First Aid; Infection Protection; Pain Management; Wound Care
NOTE:
Blisters can result from numerous conditions including burns, sunburns, rubbed areas
(like the heel of the foot from a tight shoe), infection, chicken pox and poison ivy.
Infected fever blisters (also called cold sores) on the gums, mouth, face and lips can be
highly contagious. They should subside within 7-14 days, but should be kept clean and
not touched. Medical attention is necessary if there is spreading, slow healing, an
inability of the student to refrain from touching the areas, immunosuppression, severe
pain, extensive sores or evidence of infection. (See also Impetigo, page 47.)
1. HI
2. Do not puncture. Blisters heal best with natural skin bandage.
3. Wash with mild antiseptic soap and water.
4. Apply absorbent sterile dressing.
5. If broken, treat as abrasion.
6. Observe for skin redness or drainage that might indicate infection. If present, refer for
medical
attention.
7. Notify parent/guardian if follow-up care or monitoring is indicated.
8. Future considerations:
a. Monitor for future infection or poor wound healing.

Section C - 32- 02-2006

b. For friction blisters, identify and alleviate source or pad area.
c. For sunburn, use appropriate sunscreens and sun safety.

BRUISE/CONTUSION

NIC: First Aid; Heat/Cold Application; Pain Management; Wound Care
NOTE:
Be alert for telltale signs of abuse; i.e., looped bruise, handprint or finger type bruise;
bruises in areas generally covered; multiple bruises in various stages of healing. If child
abuse is suspected, report to Division of Family Services at 1-800-292-9582 and
complete Mandatory Reporting Form (See Section D, pages 20-21).
1. HI
Consider structures underlying the skin at area of contusion and the mechanism of injury.
2. If new bruise, apply cold compress or ice for 20 minutes.
3. If old bruise, no treatment is necessary, but warm compress may provide some pain relief
and
increase healing.
4. Chart clear and objective description of bruise; i.e., 3 parallel bruises noted on anterior
left thigh, all
are reddish blue in color, one is 5 cm x 1 cm, one is 1 cm x 1 cm and one is 2 cm x 1 cm. Do
not
chart judgments as to age of injury. The following grid is for reference only.

General Stages of Bruising
Day of Bruise Color
Initial injury Red or clear
Several days Reddish blue, bluish purple or purple
5-10 days Green to yellow tint
10-14 days Shades of brown
5. Indications for medical referral:
_ Severe trauma

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_ Severe pain or warmth
_ Signs or suspicions of injury to underlying structures
_ Unknown cause of bruise
6. Indications for parent/guardian contact:
_ Injury occurs at school
_ Bruise as a result of inappropriate activity of the child, which the parent/guardian should
monitor
7. Future considerations:
a. Monitor for healing.
b. Monitor for additional bruising.

BURNS

NOTE:
Burns may be associated with abuse, intentional self-mutilation or playing with fire.
THERMAL BURNS
NIC: Emergency Care; First Aid; Heat/Cold Application; Pain Management; Vital Signs
Monitoring;
Wound Care

Section C - 33- 02-2006
NOTE:
_ Look for burns around lips/mouth or singed nasal hair. Breathing problems may
develop. Notify 911.
_ Younger (than 5) or older (than 55) individuals are at increased risk of
complications.
1. HI
2. Types/wound care:
First Degree Superficial _ Clear to deep red
_ Intact skin to blisters
_ Swelling
_ Tender/painful
Second Degree Partial thickness _ White to deep red
_ Blister(s)
_ Swelling
_ Moist
_ Mottled
_ Extremely painful
Third Degree Partial thickness, deep or
full thickness
_ Dry
_ Pearly white to charred
_ Little pain or sensation
_ Leathery, inelastic, hard
to touch
a. Superficial epidermal (First Degree)
(1) Hold under cool running water or apply cold compress until pain is relieved. Do not use
ice.
(2) Apply dry, sterile dressing.
(3) Notify parent/guardian.
b. Partial Thickness
Superficial (First-Second Degree)
(1) Put in cool water or apply cool moistened dressings to burns less than 10% Total Body
Surface area. Do not use ice.
(2) Notify parent/guardian. Advise if medical attention is needed.
Deep (Second Degree)
(1) Apply cool (not ice) moistened dressings to burns less than 10% Total Body Surface.
(2) Elevate burned extremities to about the level of the heart.

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(3) Notify parent/guardian and advise prompt medical care.
c. Full Thickness (Third Degree)
(1) Call 911 for any full thickness burn. Notify parent/guardian and administration.
(2) Apply cool moistened dressing to burns less than 10% of total body surface.
(3) Do not attempt to remove any clothing that adheres to wound.
(4) Elevate burned extremities to about the level of the heart.
(5) Keep student calm, inactive and warm.
3. Monitor and treat for shock, respiratory/cardiac distress and altered consciousness.
4. Remove jewelry and/or clothing in the immediate area of the burn. Clothing/jewelry that is
charred/dirty may impinge circulation and lead to infection if swelling occurs. Do not remove
if
adhered to the skin.
5. Do not apply antibiotic or other ointments or chemical solutions.
6. Call 911 and notify parent/guardian and administration if:
_ Burn is large or deep, on face or eye, or if ABCDs are compromised
_ Burns cover greater than 10% of body surface (10% of total body surface is approximately
the
area of one arm)
_ Third degree burn

Section C - 34- 02-2006
7. Indications for medical attention:
_ Burns to the hand or face require evaluation due to the potential for scarring
_ Need for tetanus booster
8. Future considerations:
a. Encourage activities to promote wound healing
b. Monitor for infection and possible scarring. Refer PRN.
c. Unless ordered otherwise, first degree burns should be kept moisturized to promote
healing.
An aloe vera lotion will provide pain relief and keep skin supple. This should not be applied
until skin is totally cooled.
CHEMICAL BURNS
NIC: Emergency Care; First Aid; Heat/Cold Application; Pain Management; Respiratory
Monitoring;
Vital Signs Monitoring; Wound Care
Eye
1. Irrigate eye immediately and thoroughly with large quantities of water, 20-30 minutes or
more. Tilt
head so that affected eye is lower.
2. Call Poison Control (1-800-722-7112) for further instructions. Refer to Material Safety Data
Sheets
on site.
3. Notify parent/guardian and advise medical care by an ophthalmologist or as directed by
Poison
Control (1-800-722-7112). Note chemical, whether it was acid or alkali, for treatment
purposes.
Skin
1. Flush area thoroughly with cold running water, 15-20 minutes or more. Remove clothing
and
jewelry (when swelling is a possibility) that may be contaminated, taking care not to
contaminate
self.
2. Call Poison Control (1-800-722-7112) for further instructions. Refer to Material Safety Data
Sheets
on site.

196

3. Notify parent/guardian for medical care as directed by Poison Control Center (1-800-7227112) or
if burn involves:
_ Face, hands, feet, groin or buttocks
_ Area greater than 2-3 inches
ELECTRICAL BURN
NIC: Emergency Care; First Aid; Heat/Cold Application; Pain Management; Respiratory
Monitoring;
Vital Signs Monitoring; Wound Care
1. If you are called to the scene, take care not to expose yourself or others to further
electrical shock.
Turn off current to electrical charge. DO NOT TOUCH THE VICTIM UNTIL POWER SOURCE
IS OFF.
2. Maintain ABCDs of emergency care.
3. Call 911. Notify parent/guardian and administration. All electrical burns must be evaluated
by a
healthcare provider due to the potential for cardiac dysrhythmias. Electrical burns may
appear
minimal on the surface, but can be more severe in underlying tissue.
4. HI
a. Check for entry and exit burns.
b. Consider underlying tissue damage.
5. Monitor/treat for shock, respiratory/cardiac distress and altered consciousness.
6. Cover burn with clean dry dressing.

CHILD ABUSE

NIC: Abuse Protection Support: Child
See Section D, pages 13-22.

Section C - 35 - 02-2006

CHOKING

See Section C, Airway Obstruction, pages 27-29.

COUGH
NIC: Airway Management; Allergy Management; Medication Administration; Pain
Management;
Respiratory Monitoring
NOTE:
Although rare, pertussis (“whooping cough”) has presented more frequently in recent
years even amongst those immunized. The American Academy of Pediatrics now
recommends a booster shot for children aged 11-18.
1. HIA
a. The assessment should include the throat, nose, ears and chest.
2. Reassure student as any difficulty in breathing can be frightening.
3. Identify and address any underlying or contributing factors; ex. allergic reaction, potential
upper
respiratory infection, trauma to neck, choking, etc.
4. The cough may be alleviated or reduced with frequent sips of water, a lozenge or a piece
of hard
candy. Choking precautions are important if the student is given something to suck on.
5. Notify parent/guardian.
a. Advise medical attention for:
_ Difficulty breathing
_ Stridor
_ Wheezing (if previously undiagnosed or reported)
_ Cyanosis
_ Lethargy

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_ Cough with a “hoop” or “whoop” sound
_ Cough with blood
_ Mucous production that is foul-smelling or discolored
_ Cough lasting more than 10 days
_ Chronic cough
_ Accompanying symptoms needing attention
b. The more severe the accompanying symptoms, the more promptly medical attention are
required.
c. Discuss with parent/guardian when to seek medical attention.
d. Share ways to diminish the cough:
(1) Increase humidity in the home.
(2) Increase fluid intake.
(3) Consult with pharmacist or healthcare provider on over-the-counter medications to
decrease congestion or assist with reducing mucous.
e. KidsHealth.org provides a good overview of coughs for practitioners and
parents/guardians:
http://www.kidshealth.org/parent/general/eyes/childs_cough.html.

DENTAL
AVULSED TOOTH
NIC: Bleeding Reduction: Wound; First Aid
1. HI
2. Notify parent/guardian and advise dental care.

Section C - 36 - 02-2006
3. Partially avulsed tooth
a. Reposition in mouth for stability.
4. Complete tooth avulsion
a. This is a dental emergency and care must be taken to replant tooth within 30 minutes.
b. Contact the parent/guardian for immediate transport.
c. Limit handling of avulsed tooth. Hold by the crown and not the roots.
d. Gently rinse the tooth in cool tap water. Do not use soap or other cleanser. Do not scrub.
e. Tooth should be placed in tooth socket to preserve and increase viability if possible.
f. If replantation takes longer than 30 minutes and the student is unable to hold in tooth
socket,
place tooth in moist saline gauze or milk during transport. Commercial products are also
available.
5. Future consideration:
a. Encourage mouth protection/guards during sport activities.
FRACTURED TOOTH
NIC: Bleeding Reduction: Wound; First Aid; Pain Management
NOTE:
Tooth injury may be related to falls, sports related activities, physical abuse or foreign
bodies (ex. tongue piercing).
1. HIPa
2. Observe for bleeding around gums, pain or chipped tooth.
a. External palpitation of the face and neck assesses for possible skeletal trauma with
accompanying tenderness and lymph node involvement indicates possible infection.
3. Notify parent/guardian and advise prompt dental care.
4. Future considerations:
a. Encourage mouth protection/guards during sport activities.
b. Discuss effect of some oral jewelry on teeth integrity.
LOOSE TOOTH (shedding of baby/deciduous tooth)
NIC: Bleeding Reduction: Wound; First Aid; Pain Management
1. HI
2. Encourage child to wiggle tooth to promote avulsion.
3. Indications for parent/guardian contact to refer for dental evaluation:

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a. Permanent teeth appear to be erupting prior to shedding of baby teeth.
b. Child indicates significant discomfort.
c. Deciduous tooth loss is not within normal growth and development guidelines.
ORTHODONTIA
NIC: Pain Management
1. HI
2. If wire is embedded in gum, cheek tissue or tongue, do not remove. Notify
parent/guardian and
refer for prompt medical care.
3. If wire is protruding and causing irritation, dental wax applied over the protruding wire can
provide
immediate relief. Notify parent/guardian and refer to orthodontist for repair of wire.
TOOTHACHE
NIC: Pain Management
1. HI
2. Notify parent/guardian and advise dental care for pain due to dental caries, hot or cold
sensitivity,
abscess, gum swelling or foul odor.

Section C - 37 - 02-2006
3. Give analgesic, if directed by parent/guardian.
4. A compress, warm or cool, may provide some pain relief. Choice of temperature will
depend upon
student’s comfort.
5. Future considerations:
a. Encourage good oral health care, including routine dental exams.
b. Encourage a healthy diet, including snacking.
c. Determine fluoridation status of family/community water and advise PRN.

DIARRHEA/VOMITING

NIC: Diarrhea Management; Rest
NOTE:
• Diarrhea can be acute or chronic. It is characterized by frequent loose, watery
stools, often accompanied with abdominal cramping. Acute diarrhea will likely
subside on its own, but it is important to identify the cause and to monitor closely for
dehydration.
• The CDC defines “chronic diarrhea” as “diarrhea that lasts for more than 2 weeks
is considered persistent or chronic. In an otherwise healthy person, chronic
diarrhea may be a nuisance problem, or, for someone who has a weak immune
system, a life-threatening illness.”
(http://www.cdc.gov/ncidod/dpd/parasites/diarrhea/factsht_chronic_diarrhea.htm)
• Do not give antidiarrheal without doctor’s order.
• Vomiting may be associated with diarrhea or gastric symptoms.
• For both diarrhea and vomiting, it is important to assess and monitor for
dehydration and to determine underlying causes of the symptoms.
1. HIAPePa
a. History
(1) Note the onset, allergies, antibiotic therapy, recent diet, and recent travel to a foreign
country.
(2) Food poisoning has a 2-6 hour incubation period, prominent vomiting and typically
several people are affected.
(3) Vomiting may be associated with motion sickness, inner ear disturbance, stress or
pregnancy. In these cases, vomiting is usually self-limiting.
2. Fluid loss is of primary concern with diarrhea or vomiting.
a. Diarrhea: Clear broth, flavored gelatin, sport drinks or flat carbonated beverages are
helpful
to replace fluid. Water alone may not be adequate.

199

b. Vomiting: Only small sips (1 teaspoon to 1 ounce) of clear fluid should be encouraged.
c. Observe for signs of dehydration, fever, dry mouth, decreased urination, drowsiness,
sunken
eyes, bloody or dark stool/vomitus, severe or prolonged abdominal pain, inability to hold
down fluids for 8 hours, headache, stiff neck and lethargy. If any of these symptoms are
present, notify parent/guardian and advise immediate medical care.
3. Exclusion of the student is indicated if:
a. Diarrhea/vomiting is due to infection.
b. Student has more than three loose stools or requires frequent trips to the bathroom.
c. Diarrhea/vomiting is accompanied with fever or discomfort.
4. Notify parent/guardian and advise medical evaluation:
_ Diarrhea lasting more than 2 days
_ Fever
_ Vomiting
_ Severe pain
_ Unusual stools
_ Any signs of dehydration

Section C - 38 - 02-2006
_ Pregnancy
5. Future consideration:
a. Encourage frequent and good handwashing.

DYSMENNORRHEA

NIC: Medication Administration; Pain Management; Rest
NOTE:
Prostaglandins produced 1-2 days prior to the start of the menstrual cycle account for
many of the pre-menstrual symptoms causing missed school time, including cramping.
Prostaglandin inhibitors can be very effective in relieving these symptoms. Nurse should
develop an Individualized Healthcare Plan (IHP) to help students lessen the severity of
PMS and dysmennorrhea and lost time at school.
1. HI
2. Allow student to rest for short time.
3. Give analgesic, if directed by parent/guardian or healthcare provider.
4. Indications to notify parent/guardian and refer for medical evaluation:
_ Severe or recurrent pain
_ Heavy bleeding
_ Pain interrupts daily activities each month
_ Change in menses
_ Loss of school time due to pain
5. Future consideration:
a. Encourage exercise to facilitate muscle tone and routine bowel movements.

EAR

NOTE:
Ear pain or foreign body may be a result of an injury. Consider and evaluate for head
trauma.
FOREIGN BODY
NIC: First Aid; Pain Management
NOTE:
An impaled object should be stabilized so that the student can be transported without
further damage from the object.
1. HIPa
2. Only attempt removal if foreign body is easily visible upon external examination and
easily
grasped.

200

3. If the object is a live insect, instill a few drops of mineral oil to the affected ear. Do NOT
instill if
there is any disruption in the tympanic membrane (i.e., tubes or injury). A flashlight beam
may
attract a live insect out of canal.
4. For other foreign bodies, do not irrigate the ear as it may cause swelling of the object and
make
removal difficult.
5. Notify parent/guardian and advise medical care and evaluation.
6. Future consideration:
a. Teach children not to put anything into their ears, including cotton swabs.

Section C - 39 - 02-2006
INJURY
NIC: Bleeding Reduction; First Aid; Heat/Cold Application; Pain Management; Wound Care
1. HI
2. If foreign body, refer to text above.
3. If bleeding externally, treat accordingly. (Refer to Wounds, Abrasions/Lacerations, Section
C,
pages 54-55)
4. If bleeding from ear canal:
a. Cover outside of ear with sterile dressing.
b. Lie on affected side.
c. Consider head/neck injury and treat/immobilize accordingly.
d. Monitor for shock.
e. Call 911. Notify parent/guardian and administration.
5. If bruise/contusion, refer to Bruise/Contusion, Section C, page 31.
PAIN
NIC: First Aid; Heat/Cold Application; Pain Management
1. HIPa
a. Determine if febrile.
b. Observe for pain with movement of auricle, tragus and pinna.
c. Observe for nasal discharge and respiratory congestion.
d. Otic exam can evaluate condition of ear canal and tympanic membrane.
(1) Fluid in the ear may cause erythematous and dull tympanic membrane with dull light
reflex and difficulty visualizing landmarks. Tympanic membrane may appear to
bulge with increased fluid pressure within middle ear.
(2) Edema, tenderness and erythemal of the canal may be visualized.
e. Observe for drainage.
(1) White or yellow discoloration of tympanic membrane may be present with infection.
2. Notify parent/guardian and advise medical care for abnormal signs and symptoms.
3. A warm moist compress may help alleviate some pain. Apply to affected ear and lie on
unaffected
side, unless there is drainage.
4. Future consideration:
a. Observe and refer for allergy symptoms, frequent pain or frequent congestion.

EYE

NOTE:
Immediate medical attention is needed for any sudden loss of vision or blurriness.
CHEMICAL BURNS (Refer to Burns, Chemical Burns, Eye, Section C, page 33)
CONJUNCTIVITIS
NIC: Heat/Cold Application; Medication Administration; Pain Management
NOTE:
If student wears contacts, advise removal and use of glasses during course of illness.
1. HI
2. Allergic conjunctivitis

201

a. Conjunctiva may be red and both eyes may itch and burn, with clear tearing.
b. Observe for excessive rubbing of eyes and swollen, pale nasal mucosa.
c. Remove contacts.

Section C - 40 - 02-2006
d. Apply cold compress.
e. Notify parent/guardian and advise medical care for:
(1) Symptoms of infection;
(2) Accompanying, undiagnosed allergy symptoms.
NOTE:
In the case of bacterial or viral conjunctivitis:
_ Wash hands frequently and thoroughly.
_ Keep hands away from eyes.
_ Discard eye make-up.
_ Discontinue contact lens use until course of medication is completed.
_ Avoid sharing eye make-up.
_ Change personal towel, face cloth and pillow case often. Do not share.
3. Bacterial conjunctivitis
a. Assess eyes for red/pink sclera, inflamed lining of eyelid, photophobia, moderate tearing,
minimal itching, purulent discharge, dried discharge on eyelids and swollen eyelids.
b. Remove contacts.
c. Notify parent/guardian and refer for medical care.
d. Exclude from school until treatment is implemented or symptoms are gone for 24 hours.
4. Viral conjunctivitis
a. Assess eyes for red/pink sclera, inflamed lining of eyelid, profuse tearing, minimal itching,
sudden onset photophobia and pre-auricular node. Initially only one eye is involved.
b. Remove contacts.
c. Apply cold compress for comfort.
d. Advise student to keep hands away from eyes.
e. Notify parent/guardian to advise medical care if needed.
f. The student should be excluded from school until the following conditions are treated
and/or
resolved:
(1) Increased drainage or symptoms
(2) Symptoms of bacterial infection; i.e., treatable
(3) Being unable to refrain from touching eye(s)
5. Future considerations:
a. Monitor other students for possible infection.
b. Encourage routine and thorough handwashing.
CORNEAL ABRASION
NIC: First Aid; Pain Management
NOTE:
Contact lenses are a common source of corneal abrasions if worn too long or if foreign
body is trapped between lenses and cornea. Foreign bodies may cause corneal
abrasions as well as more severe injuries to the eye.
1. HI
a. Student will have pain, tearing, sensation of foreign body still in the eye, and
photophobia.
b. Visual acuity may be normal or slightly decreased.
2. Patching
NOTE:
Reference texts differ in recommendations regarding patching.
a. In general, it is advised that the eye be at rest until medical examination. The student
may be
willing and able to voluntarily keep his/her eyes closed.

Section C - 41 - 02-2006
202

b. In the event of bleeding, pain or other condition, the affected eye may be better protected
with patching. The student may be able to tolerate the patching of both eyes.
c. Small lesions with minimal discomfort may not need patching.
3. Notify parent/guardian and advise medical care from an eye specialist.
FOREIGN BODY
NIC: First Aid; Pain Management; Wound Care
NOTE:
If object is sticking out of the eye or embedded, do not touch or attempt removal. Seek
immediate medical attention.
1. HI
a. History is important because exposure to metal components in the eye have potential for
continued injury.
b. Determine if student is wearing contact lenses. Contacts should not be removed.
c. If there is a possibility of a metal foreign body, seek medical attention.
2. If the object is visible and floating such as an eyelash, encourage blinking. Flush well with
lukewarm water until object is out.
3. Treat as corneal abrasion (see above) if unsuccessful in removing the foreign body, or for
continued
pain, redness, tearing, sensitivity to light or discomfort.
4. Notify parent/guardian and advise medical care. Immediate medical attention is indicated
if:
_ Unable to remove object
_ Continued redness
_ Pain
_ Any signs of corneal abrasion
_ Any visual changes or complaints
5. Future consideration:
a. Encourage protective eyewear whenever engaging in a potentially hazardous activity that
can lead to trauma, dust/foreign body, chemical insult or heat to the eye.
INJURY (blow to the eye)
NIC: First Aid; Pain Management; Wound Care
NOTE:
Any severe blow to the eye requires medical attention. Head trauma and sports injuries
can lead to a detached retina. An orbital fracture or hyphema may occur with a blunt
force injury with a fist or ball such as a baseball, tennis ball or even a badminton birdie.
Any penetrating trauma requires stabilization of the eye using a paper cup or similar
object.
1. HI
2. Do not attempt to remove contacts.
3. Call 911. Notify parent/guardian and administration.
4. Apply cool compress, but avoid any pressure.
5. Encourage student to rest or lie comfortably with head elevated and eyes closed.
6. Future consideration:
a. Encourage protective eyewear whenever engaging in a potentially hazardous activity that
can lead to trauma, dust/foreign body, chemical insult or heat to the eye.
STY
NIC: Pain Management; Wound Care
1. HI

Section C - 42 - 02-2006
2. Remove contacts.
3. Gently apply warm compress to outer eyelid for 10 minutes.
4. Do not attempt to open the sty.
5. Indications for medical referral:
_ Interference with vision
_ Persistent, beyond several days

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_ Reoccurring
_ Spreading
6. Future consideration:
a. Encourage use of warm compress several times a day until clear.

FAINTING

NIC: Emergency Care; First Aid; Rest; Vital Signs Monitoring
1. Maintain ABCDs of emergency care.
2. HI
a. If unconscious, obtain history from observer.
b. History is very important to determine possible etiology; for example, hypoglycemia in
student with diabetes, unobserved seizure or cardiac condition (often associated with
exercise).
c. Assess for dehydration, heat stroke, heart condition and injury (due to fall).
3. Have student preferably lie flat with legs elevated above head. Other acceptable
positions: lie on
side with legs elevated or sit with head between knees.
4. Loosen clothing, i.e., belt, scarf, collar, etc.
5. If heat is suspected, move student to cooler place. If conscious, and fully recovered,
student may
have liquids by mouth.
6. Call parent/guardian and advise medical care for any fainting spell.

FATIGUE/MALAISE

NIC: Counseling; Medication Administration; Rest
1. HIAPePa
a. A thorough assessment is indicated to determine both cause and associated symptoms.
b. In addition to physical assessment (ex: cardiovascular, gastrointestinal), consider the
following:
(1) Sleep patterns
(2) Physical exertion and work habits
NOTE:
Both inactivity and excessive physical activity can lead to fatigue.
(3) Psychosocial issues
(4) Diet habits
(5) Current medications
If these are normal, fatigue may be symptomatic of an underlying disorder.
2. If sudden, persistent, accompanied with other symptoms needing attention or of unknown
etiology,
notify parent/guardian and advise medical evaluation.

Section C - 43 - 02-2006

FEVER

NIC: Fever Management; Medication Administration; Rest; Vital Signs Monitoring
NOTE:
_ Mercury thermometers should not be used in school and should be properly disposed.
Contact Delaware Solid Waste Authority for specific information at
http://www.dswa.com.
_ Reference texts disagree on one specific temperature value for a “fever.” Normal
temperatures typically fall between 97.6 to 99.6 orally; however, temperatures can
fluctuate during the day or specific activities. There are many reasons a student may
develop a fever and the underlying cause should be determined through a thorough
nursing assessment. Exclusion should be based on the student’s symptoms, possible
communicability, comfort level and temperature (based upon his/her normal value).
_ Axillary temperatures run one degree lower than oral ones. Rectal temperatures run
one degree higher.
1. HI

204

a. Assess for infection related to bacterial, viral or parasites.
b. Assess for dehydration and provide interventions PRN.
2. Control fevers by acetaminophen or ibuprofen if you have written parent/guardian
permission and/or
physician direction. Do not give aspirin.
3. Exclude student for temperatures over 100.6ºF or temperature elevation combined with
other
symptoms.
a. A student, who is excluded due to fever, should have a temperature within normal range
for 24
hours without an antipyretic prior to returning to school.
4. Notify parent/guardian and advise medical consultation if:
_ Sudden spike in fever
_ Persistent fever
_ No obvious reason for fever
_ Fever in children above 101º
_ Symptoms of infection or communicable disease

HEAD/NECK INJURY
NIC: Emergency Care; First Aid; Heat/Cold Application; Neurological Monitoring; Pain
Management;
Rest; Vital Signs Management; Wound Care
NOTE:
Whenever a head injury occurs, consider accompanying injury to the neck/spine and vice
versa.
While most injuries at school are minor, they can be serious and should be assessed
thoroughly and appropriately referred for any concerns or unusual symptoms/complaints.
1. Maintain ABCDs of emergency care.
2. HIPa
a. History and mechanism of injury will yield important clues to injuries that may not be
readily
visualized.
b. Assess level of consciousness and the duration of any loss of consciousness following the
injury. The Glasgow Coma Scale is helpful when assessing injury and provides a baseline for
future evaluation in serious head injuries. It can be accessed at
http://www.bt.cdc.gov/masstrauma/gscale.asp.
c. Assess neurological status and personality/judgment since the event. Consider:

Section C - 44 - 07-2007
(1) Judgment, problem-solving
(2) Orientation to time and place
(3) Memory
(4) Affective disturbance
(5) Calculation disturbance
d. Assess for dizziness, headache, nausea or vomiting, confusion, and pallor. Do not move
the
student until fully assessed.
3. Call 911 and notify parent/guardian and administration for:
_ Any altered level or loss of consciousness
_ Any clear or bloody fluid from ears/nose
_ Darkness/bruising below eyes or behind ears
_ Decreased blood pressure
_ Dizziness
_ Loss of bowel or bladder control
_ Neurological/visual/respiratory changes
_ Seizure
_ Severe bleeding to face or scalp

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_ Slurred speech
_ Stiffness or pain in neck
_ Tingling, paralysis or weakness of extremities
_ Unequal pupils
_ Vomiting/nausea
4. Have student lie flat and apply ice to injured area.
5. Immobilize for any suspected neck injury.
6. Monitor/treat for shock.
7. Caution:
a. Do not remove head gear or hat.
b. Do not wash the wound if there is a deep wound, imbedded object or severe bleeding.
c. Do not apply pressure to stop bleeding if fracture is suspected.
8. If student has only bumped his/her head and does not have any other complaints or
symptoms,
a. Treat with ice to injured area.
b. Observe throughout day for delayed symptoms.
c. Notify parent/guardian of head injury. Advise continued observation for 24 hours and
discuss
signs of a serious head injury that would need medical attention.
9. Future considerations:
a. Traumatic Brain Injury (TBI) can occur with little or no loss of consciousness. Be alert for
possible symptoms over next weeks and months.
b. Localized external swelling to head; i.e., “goose egg”, may take weeks to subside.
c. Encourage head protection during sport activities.

HEADACHE

NIC: Pain Management
NOTE:
Many children experience headaches and headaches are a universal reason for students to
see the school nurse. Headaches are usually benign and result from tension or migraines.
Headaches are commonly associated with:
* Allergic response * Caffeine * Carbon monoxide poisoning
* Common cold * Dehydration * Fever
* Food poisoning * Hangover * Head/neck injury
* Heat exhaustion * Hormonal changes * Infection
* Loud sounds * Lyme Disease * Medication
* Multiple insect stings * Shock * Smoking
* Sleep pattern disturbances or deprivation * Stress
* Strong odors * Tooth abscess * TV/computer watching for
* Urinary tract infection extended period of time
* Withdrawl from alcohol, caffeine, drugs, and medication

Section C - 45 - 07-2007
Rare causes are:
* Aneurysm * Brain Tumor * Encephalitis
* Encephalitis * Meningitis * Stroke
* Transient ischemic attack
Additional references on headaches include:
* Kolar, Fisher & Gordon, (2001) “Nurse, My Head Hurts”: A Review of Childhood
Headaches. JOSN, 17, (3). Pp. 120-125.
* http://www.umm.edu/ency/article/003024.htm
* http://www.mayoclinic.com/health/headaches/HQ00428
1. HIPePa
a. Determine:
o Location
o Level of pain using the Wong-Baker Faces Pain Rating Scale at
http://www.intelihealth.com/IH/ihtIH/WSIHW000/29721/32087.html#wong or the numeric

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scale (0-10 with 0 being no pain and 10 the worst, unbearable pain)
o Quality – dull, aching, acute, throbbing, pressure
o Quantity – intensity, how much pain is there
o Chronology – how has the pain changed since it started?
o Setting – where was the student when it started hurting? What was he/she doing?
o Aggravating and alleviating factors
o Associated manifestations – what happened when it started (nausea, vomiting, vision
changes)?
o Diet/sleep/tension/other associated symptoms
b. History
o Relation to menstrual cycle, diet, post gym, sleep, medications, emotions
o Ask specifically about the use of oral contraceptives
c. Physical Signs – vital signs, neurologic assessment, muscle tone
o Inspect head and face; palpate for tenderness.
o Are the lymph nodes enlarged?
o Assess eyes, ears, nose, and throat.
d. Red Flags – sudden onset, increasing severity, severe pain on awakening, seizures, history
of head
trauma, fever, nuchal rigidity, increasing blood pressure, irritability, change in behavior,
lethargy,
slurred speech, extremely specific pain, petechiae or ecchymosis, and vomiting without
nausea
2. Notify parent/guardian and refer for medical attention if:
• Altered behavior or personality
• Altered consciousness, lethargy, or confusionBalance or gait disturbance
• Bruising or petehiae
• Fever
• Head injury or history of head injury
• Increased blood pressure
• Increasing irritability
• Neck stiffness or pain
• Pain that wakes student from sleeping or is present upon waking
• Persistent, progressing severity and frequency of headache during short time frame
• Seizure
• Skin rash
• Sudden onset
• Tingling
• Violent or incapacitating pain
• Visual disturbances
• Vomiting and nausea
3. Nursing Interventions – reassurance, rest in dark, quiet room for 15-30 minutes,
carbohydrate snack,
relaxation techniques, massage the neck and temples, ice packs to occipital region, or apply
cold
washcloths over eyes for 20 minutes
a. For children with frequent c/o of headaches:
1) Encourage independent management of pain. Praise and reward normal activity when
report of
pain has been made.

Section C - 46 - 07-2007
2) Encourage parents to treat pain requiring a reduction in activity as an illness. The child
should
remain in bed even if pain has resolved. Do not permit watching television, playing games,
or
special treatment.

207

3) Encourage and educate the parents and the student about the need to maintain a diary
about
headaches.
4) Reduce response to pain behavior.
5) Encourage student to discuss feelings use open-ended questions.
6) Counseling, stress management, and behavioral therapies such as biofeedback should be
considered.
7) Indoor air quality may affect headaches and need further investigation.
8) Consider dietary intake and allergies. (Potential dietary precipitants include: cheese,
processed
meats, chocolate, nuts, pickles, and monosodium glutamate).
b. Administer analgesics according to district policy, IHP, and parent/guardian permission
1) Many children respond well to ibuprofen. Consider any contraindications: bleeding
disorders,
GI issues, other medications, frequency of use
2) It is important to take enough medication, use the medication early in the course of the
headache, and have medication available at all times.
3) It is important to address the cause of the headache, rather than to mask the symptoms
with
analgesics.
c. Refer child to doctor if headache requires the child to be sent home more than once a
semester.
1) The International Headache Society suggests that if analgesics are used more than 9 days
each
month for headache, the child should be assessed by a physician.
2) Based upon diagnosis, an IHP may be needed.
4. Additional references on headaches include:
National Headache Foundation. Impact of headache on children at school and with their
families.
http://www.headaches.org/consumer/educationalmodules/childrensheadache/aghome.html
Andrasik, F. & Schwartz, M.S. (2006). Behavioral assessment and treatment of pediatric
headache.
Behavior Modification, 30(1), 93-11

HEART ATTACK OR CARDIAC ARREST
NIC: Emergency Care; Vital Signs Monitoring
NOTE:
School nurses should hold current certification in CPR. Signs of cardiac arrest are diverse
and vary in intensity. Women often present with more subtle symptoms and ones seemingly
unrelated to chest pain, like viral symptoms. Classic symptoms:
_ Chest pain/discomfort, possible after stress or exertion
_ Constant crushing, tightness, fullness or squeezing pressure
_ Pain radiating to jaw, arm, shoulder, neck, teeth, back or stomach
_ May present as “indigestion”
_ Pale skin, cool to touch
_ Sweating, likely profuse
_ Pulse: rapid, irregular and/or weak
_ Nausea/vomiting
_ Respiration: shortness of breath, rapid, shallow and/or difficult
_ Unconscious, partial collapse, weak or dizzy
_ Anxious and/or fearful
_ Chest pains should be evaluated.
1. Maintain ABCDs of emergency care.
2. Call 911. Do not delay. Notify parent/guardian and administration.
3. Bring AED to site.
4. Monitor airway, breathing and vital signs.

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a. If conscious, keep calm and reassure student. Have him/her rest comfortably, but do not
lie
down.
b. If unconscious, position in recovery position.
5. Future considerations:
a. Provide education to staff on early signs of cardiac arrest and CPR.
b. Determine if an AED is needed in the school based upon student/faculty profile.

Section C - 47 - 02-2006

HEAT EMERGENCIES
NIC: Emergency Care; Heat Exposure; Neurological Monitoring; Rest; Vital Signs Monitoring
NOTE:
Heat cramps may be the first sign of heat exhaustion, which untreated leads to heat
stroke.
HEAT CRAMPS
NOTE
Muscle cramps occur during exercise most often due to inadequate fluid replacement
during exercise.
1. HI
2. Move student to cool area.
3. Gently massage affected muscles.
4. If no vomiting, replace fluids with sports drink, such as Gatorade.
5. If no improvement or accompanied with other symptoms, notify parent/guardian and refer
for
medical attention.
HEAT EXHAUSTION
NOTE:
Heat exhaustion is usually triggered by exercise in hot weather, with fluid loss through
sweating.
1. HI
a. Assess body temperature.
b. Student will likely present with:
_ Pale, ashen skin
_ Cool, moist skin and sweating profusely
_ Weakness or altered mental status
_ Dizziness, nausea/vomiting and headache
_ Hypotension, tachycardia, tachypnea and severe thirst
_ Dark urine
_ Muscle cramps
_ Temperature elevation from slight to 104º
2. Treatment:
a. Student should be placed in cool environment, preferably an air-conditioned area, lying
flat
with feet elevated.
b. If not vomiting, give sports drink or clear juice.
c. Place cool wet cloths on forehead and body.
d. Use mist and fan to cool student.
e. Loosen clothing and remove extra layers.
f. Monitor for shock.
3. Notify parent/guardian. Advise medical care if symptoms are severe, become worse or
persist
longer than one hour.
4. Future considerations:
a. Encourage wearing light, loose clothing during exercise and activities in the heat.
b. Maintain adequate hydration.
c. Avoid overheating if student is on medication that impairs heat regulation or is obese.

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d. Review sun safety with students.

Section C - 48 - 02-2006
HEAT STROKE
NOTE:
This is a medical emergency. The student can no longer control his central
thermoregulation mechanisms.
1. Maintain ABCDs of emergency care.
2. HI
a. The student will present with:
_ Reported exertion in hot environment
_ Core temperature is greater than 104º-106º
_ Mental status may be confused, non-responsive, irrational
_ Skin is red, hot and dry
_ Hypo/hypertension and tachycardia (with shallow or very strong pulse)
3. Treatment
a. Call 911. Notify parent/guardian and administration.
b. Move to cool environment, preferably with air conditioning.
c. Apply cool, wet cloths to neck, forehead and groin. Use fan to keep cool, but do not chill.
d. Monitor temperature and watch for shock.
e. If alert and not vomiting, give sips of clear juice or sports drink. Do not give caffeine.
f. Loosen clothing and remove any extra layers.
g. Do not give antipyretic.
h. Notify parent/guardian and administrator.
4. Future considerations:
a. Encourage wearing light, loose clothing during exercise and activities in the heat.
b. Maintain adequate hydration.
c. Avoid overheating if student is on medication that impairs heat regulation or is obese.
d. Review sun safety with students.
e. Share Parent Fact Sheet with staff and families:
http://www.kidshealth.org/parent/fitness/safety/heat_exhaustion_heatstroke_sheet.html.

IMPETIGO
NIC: Skin Surveillance; Wound Care
1. HI
a. Impetigo presents as isolated pustules or clusters of bumps, which rupture with yellow or
honey crusting. The skin is red and oozing. It typically appears on the face or hands.
b. The infection spreads quickly. It is usually caused by a break in the skin being infected
with
either staphylococcal or streptococcal infection.
2. Notify parent/guardian and refer for medical care.
3. Impetigo is contagious and students should be excluded from school for 48 hours after
treatment
has begun to prevent the spread to classmates.
4. Future considerations:
a. Monitor and assist with compliance with treatment.
b. Observe for new infection or spreading.
c. Encourage good handwashing, keeping fingernails short and clean and avoiding touching
wound sites. Primary Healthcare Provider may recommend covering some areas.
d. Promote healing by gently washing off crusted areas with warm soap and water.
e. Systemic infection or scarring is rare.
f. Clean wounds thoroughly.
g. Items such as clothing, towels or bed linens that have been infected should be thoroughly
washed in hot water.

Section C - 49 - 02-2006

INSULIN REACTION

210

NIC: Hypoglycemic Management
See Section C, pages 87-90.

MUSCULOSKELETAL INJURIES
NIC: Bleeding Reduction: Wound; Emergency Care; First Aid; Heat/Cold Application; Pain
Management
BACK AND NECK INJURY
See Head/Neck Injury, Section C, pages 42-43.
DISLOCATION AND FRACTURES
NOTE:
_ Any dislocation or fracture is an emergency situation due to possible disruption in
blood flow and injury to nerves.
_ It is difficult to distinguish between dislocation and fractures. A medical evaluation
is required.
1. HIPa
a. Note mechanism of injury and force of injury.
b. Assess range of motion and observe for deformity, guarding, pain, joint tenderness,
decreased movement, bruising, swelling and asymmetry.
c. Always assess and record peripheral neurovascular status.
2. Treatment
a. Dislocation or Simple Fracture
(1) Immobilize affected area in position found unless neurovascular status impaired. Do
not attempt to straighten or return to normal alignment.
(2) Apply ice to reduce swelling.
(3) Elevate if possible to reduce swelling.
b. Open Fracture
(1) Cover entire wound with sterile dressing.
(2) Control bleeding using standard precautions. Do not apply tourniquet.
(3) Immobilize affected area.
(4) Assess neurovascular status.
3. Call 911 for open fractures. Alternative transportation may be considered for dislocations
or simple
fractures. Notify parent/guardian and administrator.
4. Future consideration:
a. Stress fractures can occur in athletes.
SPRAINS AND STRAINS
NOTE:
It is difficult to distinguish between sprains (injury to ligament) and strains (injury to
tendons). Symptoms are similar to fractures and a medical evaluation is needed.
1. HIPePa
a. Symptoms include pain, difficulty weight-bearing, and swelling.
2. Treatment: RICE – Rest, Ice, Compression and Elevation
a. Ice should be applied for 20 minutes at a time.

Section C - 50 - 02-2006
b. Use elastic bandage to provide support and reduce swelling.
3. Notify parent/guardian and advise medical care to rule out fracture.
4. Future consideration:
a. Elevation during the first 24 hours helps to reduce swelling.

NECK
See Head/Neck Injury, Section C, pages 42-43.

NOSE

EPISTAXIS
NIC: Bleeding Reduction: Nasal
NOTE:
Nosebleeds may be caused by nose picking, strong or frequent nose blowing, foreign

211

body, excessive dryness, rhinitis, injury, allergies, extreme hot/cold air, infection,
bleeding disorder, chemical irritant or high blood pressure.
1. HI
a. Consider possible head injury.
b. Determine medications and underlying health conditions as possible contributing factor.
2. If injury, see Fracture (below) or Wounds (Section C, page 54-59).
3. Control bleeding
a. External bleeding:
(1) Treat as wound (see Wounds, Abrasion/Laceration, Section C, page 54-55).
b. Anterior Epistaxis (bleeding out front of nose) or Posterior Epistaxis (bleeding down
throat):
(1) Pinch nose together at fleshy area. Hold for approximately 10 minutes.
(2) If bleeding does not stop, repeat pinch for 5 minutes. Apply cold/ice compress to
bridge of nose.
4. Notify parent/guardian and advise medical care if:
_ Unable to stop bleeding after 15 minutes
_ Student feels weak or faint
_ Excessive blood loss
_ Injury
_ Pale with tachycardia
_ Student is taking medication with blood-thinning effect
_ History of difficulty with blood clotting
5. Document contributing factors and amount of bleeding.
6. Future considerations:
a. For the remainder of the day: discourage nose blowing, picking or rubbing
b. If nasal mucosal dryness is a contributing factor, encourage increased air humidification.
Nasal membranes can be moisturized with thin layer of petroleum jelly.
c. Students with frequent nosebleeds should be referred for medical evaluation.
FOREIGN BODY
NIC: First Aid; Respiratory Monitoring
1. HI
a. Associated symptoms: difficulty breathing; sensation of something being in the nose;
purulent nasal draining; foul odor
2. Instruct student to breathe through the mouth and avoid inhaling through nose.

Section C - 51 - 07-2007
3. Instruct student to gently blow nose in attempt to dislodge and remove foreign object. It
may be
helpful to gently occlude the unaffected nostril.
4. If the foreign body is clearly visible and easily grasped, remove gently with tweezers. Do
not probe
or insert other object into the nose.
5. Notify parent/guardian and advise medical care if:
_ Purulent nasal discharge or foul odor
_ Unable to remove object
_ Possible infection
_ Difficulty breathing
_ Noisy breathing
FRACTURE
NIC: Bleeding Reduction: Nasal; First Aid; Respiratory Monitoring
NOTE:
Facial fractures are frequently associated with nose fractures. Always consider a
possible head/neck injury and monitor breathing.
1. Maintain ABCDs of emergency care.
2. HIAPa
a. Possible symptoms: bleeding, soft tissue swelling, hematoma, periorbital ecchymosis,

212

deformity and crepitis (on palpation)
3. Instruct student to breathe through nose. Sit with head bent slightly forward.
4. Apply cold/ice compress or ice to nose to reduce swelling and pain. Do not apply pressure
or pinch
nose.
5. Notify parent/guardian and advise immediate medical care.
RHINITIS
NIC: Medication Administration; Rest
NOTE:
Rhinitis is most commonly seen with viral or bacterial upper respiratory infections.
1. HIAPePa
a. Pale turbinates usually indicate an allergic rhinitis.
b. Thickened nasal mucous membranes may indicate chronic rhinitis.
2. Notify parent/guardian and advise medical care if:
_ Fever
_ Symptoms are chronic
_ Swelling interferes with breathing
_ Possible infection or undiagnosed allergy

PAIN

NIC: Pain Management
NOTE:
Pain is associated with many conditions. The severity of pain can be assessed using the
Wong-Baker Faces Pain Rating Scale at
http://www.intelihealth.com/IH/ihtIH/WSIHW000/29721/32087.html#wong. This is the
scale most preferred by children and adolescents. A numeric scale (0-10) may also be
used in lieu of the Wong-Baker. The numeric scales uses “0” as no pain and “10” as the
worst, unbearable pain.
Lack of pain assessment is frequently cited as a major cause of unrelieved pain in both
children and adults. Pain can cause sleep disturbances and pain medications can cause
drowsiness affecting children’s ability to concentrate in school. Approximately 37% of
student visits to the school nurse involve pain.

Section C - 51a - 07-2007
1. HI
a. Assessment should take into account the age of the student, type of pain, history, and
context of
the pain, and parental influences.
b. Objectives for assessment
o Detect presence of pain
o Estimate potential impact of pain on individual
o Quantify the success of the intervention
c. QUESTT approach:
Q – Question the child
U – Use pain rating scales (Wong-Baker Faces Pain Rating Scale at
http://www.intelihealth.com/IH/ihtIH/WSIHW000/29721/32087.html#wong) or the numeric
scale (0-10 with 0 being no pain and 10 the worst, unbearable pain).
E – Evaluate behavior. A student in pain may compensate by engaging in diversionary
activity
such as playing or sleeping, while another child may exhibit anger and irritability.
S – Secure parents’ involvement
T - Take pain into account
T – Take action
d. Physiologic Measures – increased heart rate and blood pressure, changes in respiratory
rate and
pattern, and changes in oxygen saturation
o Must be used in conjunction with other pain assessment tools whenever possible.

213

e. Self-Report of Pain
o The Wong-Baker FACES scale is the preferred and most reliable assessment instrument of
children.
o Encourage pain diaries in students with chronic pain issues or frequent complaints of pain.
2. Nursing Intervention Strategies
a. The goal of interventions is to keep students in school. If this is not possible, then partial
or
complete return to school should be an early target.
b. Target possible underlying pain mechanisms, as well as symptom-focused management
addressing pain, sleep disturbance, anxiety, or depressive feelings.
c. Apply heat/cold pack as warranted.
d. Administer analgesics according to district policy, IHP, and parent/guardian permission.
e. Provide education regarding pain experience and pain problem, cognitive-behavioral,
behavioral
techniques (reinforcement), family interventions, physical interventions (massage, PT, OT),
and
systemic and regional pharmacological interventions.
f. Adverse school experiences are associated with increased recurrent pain levels.
g. Interventions that build up self worth and perceived academic competence may have
beneficial
effects on pain.
3. Additional References:
American Pain Society. Pediatric chronic pain: A position statement from the American Pain
Society.
http://www.ampainsoc.org/advocacy/pediatric.htm
Merkel, S. & Malviya, S. (2000). Pediatric pain, tools, and assessment. Journal of
PeriAnesthesia
Nursing, 15(6), 408-414.
McGrath, P.J. & Finley, G.A. (2005). Commentaries on pain in infants, children, and
adolescents.
PediatricPain Letter, 7(2-3). http://www.pediatric-pain.ca/ppl.

PEDICULOSIS
See Section C, pages 18-21.

Section C - 52 - 02-2006

POISONING

NIC: Emergency Care
NOTE:

In Delaware, contact Poison Control Center at 1-800-722-7112.
Poisoning can occur from any contact with a poisonous substance; i.e., through
inhalation, ingestion, skin contact, injection, etc.
1. Maintain ABCDs of emergency care.
2. HI
3. Notify Poison Control Center before proceeding with emergency treatment.
4. Be prepared to give: victim’s age, approximate height and weight, name/route of
substance
contacted, amount, time of contact, whether victim has vomited (and other symptoms) and
distance
(time) to nearest medical facility.
5. Follow instructions from Poison Control Center. Only administer anything oral on advice
from the
Poison Control Center.

RASHES
214

NIC: Allergy Management; Heat/Cold Application; Pain Management; Skin Care; Skin
Surveillance
NOTE:
The Mayo Clinic website offers a Slide Show of Common Skin Rashes with
recommendations for care. Refer to http://www.mayoclinic.com/health/skinrash/
SN00016.
Rashes have varied causes. An accurate assessment (with history, inspection and palpation)
will help
determine cause and intervention. Common causes are:
_ Allergic reactions, which may lead to hives (refer to Allergies, Section C, pages 75-78)
_ Bites and stings (refer to Wounds, Bites and Stings, Section C, pages 54-59)
_ Contact dermatitis
_ Heat rash
_ Infection (refer to Communicable Disease Control, Section C, pages 6-21), such as
Varicella,
Measles, Scarlet Fever, Scabies (see below)
_ Reactions to plants, such as Poison Ivy, Poison Oak or Poison Sumac
_ Tinea (refer to Ringworm below)

RINGWORM (Tinea)

NIC: Medication Administration; Skin Surveillance
NOTE: Ringworm is a highly contagious fungal infection that requires medical
treatment. Involved areas can be foot (tinea pedisi), genitals/buttocks/inner thighs (tinea
cruris), nails, scalp (tinea capitis), and skin (tinea corporis). Those at highest risk of
infection are athletes, pet owners, those with weakened immune status and young
children.
1. HI
a. Lesion: Typically presents as a red ring with central clearing. The borders of the patch will
expand as the center clears. The border is slightly raised, red and scaly. The entire patch
may be red.

Section C - 53 - 02-2006
b. Pruritis is likely to be present.
c. Alopecia may be present in infections of the scalp.
2. Cover lesion.
3. Notify parent/guardian and refer for treatment.
a. For area on foot or skin, a pharmacist may provide direction.
b. Infected nails, scalp lesions or unresponsive lesions (after 10 days of antifungal cream)
require a healthcare provider’s evaluation.
4. Student should be excluded from school until under treatment.
5. Future considerations:
a. Avoid sharing of combs, brushes, hats, clothing, towels, socks or shoes.
b. Avoid going barefoot in school or public area.
c. Clean mats/floors with disinfectant that destroys fungus. Particular attention is needed for
those areas where floor comes in contact with bare skin; for example, a
gymnastics/wrestling
mat or pool area.
d. Keep skin clean and dry.
e. Wash skin and clothing after perspiring.

SCABIES
NIC: Infection Protection; Skin Care; Skin Surveillance
1. HIPa
a. Symptoms include:
(1) Red, raised lesions or rash at finger webs, wrists, elbows, knees, shoulder blades,
axillary folds, belt line and/or thighs. External genitalia of males may be involved.
Females may have areas at nipples, abdomen and lower part of buttocks.

215

(2) Itching typically increases at night or after a hot bath.
(3) Itching is typically persistent and severe.
(4) Infection (typically impetigo) may be present at the lesions.
2. Contact parent/guardian and refer for prompt medical evaluation.
a. A Fact Sheet for parents is available at
http://www.kidshealth.org/parent/infections/skin/scabies.html.
3. Exclude student until medical evaluation is complete and treatment begun.
4. Future considerations:
a. The itch may persist for several days.
b. Observe for superinfection.
c. Observe for poor response to treatment. New lesions/rashes should not be present after 2
days of treatment. A second course of treatment may be required.
d. Recommend washing of any clothing, bedding, towels or other material that has had
direct
contact with skin over the previous 2 days before beginning treatment. Hot water wash and
hot dryer should be used. Objects that cannot be washed should be stored in a sealed plastic
bag/container for several weeks. Mites will die in a week if they cannot feed.

SEIZURE
See Section C, pages 97-101.

SPRAIN (see Musculoskeletal, Section C, pages 48-49)
SUBSTANCE ABUSE
NIC: Counseling; Substance Abuse Prevention; Vital Signs Monitoring

Section C - 54 - 07-2007
NOTE:
_ Substance Abuse is the misuse or overuse of any (legal or illegal, prescribed or overthecounter) medication or drug, including alcohol.
_ More information is available on Substance Abuse (Section D, pages 3-6).
_ Some drugs can create extreme aggression and illogical thinking. Consider your
own safety and that of others. The priority is to maintain ABCDs of emergency care
and get immediate medical attention. Confrontation should be avoided. It is
possible that you will not be able to reason with the student or obtain a good history.
1. Maintain ABCDs of emergency care.
2. HIA
a. Determine level of consciousness and affect; i.e., anxious, fearful, restlessness,
excitement,
irritability, decreased fatigue, paranoia/delusions, sleepiness, unconsciousness, aggression.
b. Take vital signs with attention to possible significant increase or decrease in cardiac rate,
blood pressure, body temperature, and breathing.
c. Observe for mydriasis, seizure activity, tremors, cardiac murmurs, shortness of breath.
3. Keep student from harming self.
4. Call 911 for hospital evaluation. Notify parent/guardian and administration.
5. Future considerations:
a. Monitor for continued substance abuse.
b. Encourage appropriate follow-up.
c. Support school activities and programs that address substance abuse and related
conditions.

THROAT

SORE THROAT
NIC: Fever Treatment; Medication Administration; Pain Management; Respiratory Monitoring;
Rest
NOTE:
Most sore throats are caused by viral infection. An exception is Group A streptococcus,
which accounts for 15-30% of sore throats and requires antibiotics to reduce the risk of

216

rheumatic fever. Other causes of sore throats include: allergies, common cold, dry
weather, dust, flu, foreign body in throat, overuse of voice, mononucleosis and mouth
breathing.
1. HIAPePa
a. Assessment:
o Assess vital signs; rule out respiratory distress
o Examine color of skin, oral mucosa, posterior pharynx, and tonsils
o Heavy, gray malodorous exudates can be from Epstein Barr virus
o Examine neck for adenopathy
NOTE:
Strep throat symptoms: fever, white patches on throat, bright red throat, enlarged lymph
nodes in neck, petechiae on hard palate, headache, stomachache, nausea, and vomiting.
Viral causes more likely to be associated with cough, conjunctivitis, and diarrhea.
b. History:
o How long has throat pain been present?
o Is the pain sharp or dull?
o Does the student have allergies, post nasal drip (color and quantity)?
o Is the sore throat associated with fever, headache, or abdominal pain?
o Does the student have upper respiratory tract symptoms or distress?
o Is the student sexually active or having oral sex?
o What aggravates or alleviates the pain?

Section C - 55 - 07-2007
o What is the pain level? Use the Wong-Baker Faces Pain Rating Scale at
http://www.intelihealth.com/IH/ihtIH/WSIHW000/29721/32087.html#wong or the numeric
scale (0-10 with 0 being no pain and 10 the worst, unbearable pain).
2. Nursing Interventions
a. Administer antipyretic according to district policy, IHP and parent/guardian permission if
fever
present. Provide lozenges or analgesic for pain according to district policy, IHP and
parent/guardian permission.
b. Encourage adequate fluid intake.
c. Teach student gargling with warm salt water (1/2 teaspoon per glass) to relieve throat
irritations,
remove secretions, and promote healing.
d. Provide student with lemon and honey in warm tea.
e. Eliminate irritants from environment.
f. Encourage student to discard toothbrush and use a new one when symptoms resolve.
3. Notify parent/guardian if:
a. Prompt medical attention is indicated for any difficulty in breathing, swallowing, or
drooling (in
young child).
b. Refer for medical care for accompanying halitosis, blood in saliva, dehydration, exudates
of
pharynx or tonsils, fever over 103º, hoarseness over one week, malaise, pain for more than
3 days
with no rhinitis, rash, chronic/recurring sore throat, tender or swollen glands, and/or contact
with
someone having strep infection.
c. If accompanied with elevated temperature, exclude from school (refer to Fever in this
section). If
no fever is present, the severity of symptoms should determine exclusion.
4. Future considerations
a. Symptoms should subside within a week.

TICK

(see Wounds, Bites and Stings, Tick Bite, Section C, pages 57-58)

217

TOOTH (see Dental, Section C, pages 34-36)
VOMITING (see Diarrhea/Vomiting, Section C, pages 36-37)
WOUNDS
AMPUTATION (see Amputation from Trauma or Accident, Section C, page 29)
ABRASION/LACERATION
NIC: Bleeding Reduction: Wound; First Aid; Heat/Cold Application
NOTE:
_ Some students engage in “cutting,” a purposeful self-injury. This is associated with
psychosocial issues and should be referred for evaluation. KidsHealth provides a
helpful Fact Sheet for teens.
(http://www.kidshealth.org/teen/your_mind/feeling_sad/cutting.html)
_ The potential for scarring or infection should always be considered, even with
“minor” wounds. All dirt and debris must be removed promptly.
1. HIPa
2. Control bleeding with ice, compression and elevation.
3. Determine time and depth of injury.
a. Advise medical attention if:
_ Abrasion is deep
_ Laceration is large, deep or gaping

Section C - 56 - 02-2006
_ Wound is difficult to clean
_ Tetanus booster is needed
4. If bleeding is mild or absent, gently clean wound with antiseptic soap and water, if
possible, and
bandage. An antibacterial ointment may be necessary.
5. Review wound care with student.
6. Indications for parent/guardian contact:
_ Need for medical evaluation
_ Need for observation at home
_ Injury occurs at school
_ Wound is dirty and/or there is a risk of infection or delayed healing
_ Need to review wound care
7. Future considerations:
a. Observe for signs of infection.
b. Promote wound healing.
c. Provide health education on ongoing wound care.
BITES AND STINGS
ANIMAL BITE
NIC: Bleeding Reduction: Wound; Emergency Care; First Aid; Heat/Cold Application;
Hemorrhage
Control; Vital Signs Monitoring
NOTE:
_ Dogs, cats, rodents, horses, reptiles, bats, raccoons and skunks can inflict deep
lacerations and puncture wounds and possible crushing wounds. Only warmblooded
mammals can carry rabies.
_ Often students are seen by the school nurse for bites that occurred outside of school.
The school nurse should not assume that appropriate care has been given. Notify
parent/guardian and public authorities of animal bites and assess for both student
and animal’s immunization status.
1. HIPa
2. Wound care
a. Control bleeding.
b. Clean bite area thoroughly with mild antiseptic soap.
c. Irrigate with saline or running water 2-5 minutes.

218

d. Assess vascular integrity and neuromuscular function.
e. Bandage the area.
3. Immediate medical care is needed and may require 911. Notify parent/guardian and
administration.
a. Transport any skin tissue or part (ex. earlobe) with student.
4. Determine date of last tetanus immunization
5. Notify Public Health official or SPCA of animal bite.
6. Future considerations:
a. Observe for signs of infection.
b. Promote wound healing.
c. Any classroom pet that becomes aggressive should be permanently removed from the
classroom.
d. Provide health education with student and parent/guardian on wound care.
e. Provide health education with student on avoiding animal bites.
HUMAN BITE
NIC: Bleeding Reduction: Wound; Emergency Care; First Aid; Heat/Cold Application;
Hemorrhage
Control; Vital Signs Monitoring

Section C - 57 - 02-2006
NOTE:
Human bites have not been linked with HIV transmission.
1. HIPa
2. Wound care
a. Control bleeding.
b. Cleanse wound thoroughly with mild antiseptic soap.
c. Rinse with copious amounts of normal saline.
d. Apply sterile bandage.
e. Apply cold compress to control swelling and bruising.
3. Refer for immediate medical evaluation if:
_ Skin is broken
_ Tetanus booster is needed
_ Hepatitis B vaccine is incomplete/unknown in either the victim or the biter
4. Notify administrator.
5. Indications for parent/guardian contact:
_ Skin is broken ( This creates potential for bacterial infection.)
_ Need for medical evaluation
_ Need for observation at home
_ Injury occurs at school
_ Need to review wound care
6. Future considerations:
a. Observe for signs of infection.
b. Promote wound healing.
c. Provide health education with student and parent/guardian on ongoing wound care.
INSECT STING (bees, wasps, ants, scorpions, some marine animals)
NIC: Allergy Management; Emergency Care; First Aid; Heat/Cold Application
NOTE:
_ If student has history of allergy to insect stings, follow his/her Emergency Plan.
_ Of particular concern are history of reactions (even local ones), multiple stings or
being stung in the mouth, neck or head.
1. HIPa
2. Observe for signs of anaphylaxis.
3. If insect is potentially poisonous or a known allergen:
a. Limit the student’s movements, particularly of the involved extremity. Increased
exercise/movement will increase circulation and thus spread.
b. Call 911 for poison or anaphylaxis. Notify parent/guardian and administration.

219

4. If there is a stinger, scrape off stinger with clean, hard surface. A credit card works well.
Do not
use forceps or tweezers as this may squeeze out additional venom.
5. Remove jewelry from areas distal to the sting.
6. Clean with mild antiseptic soap.
7. Apply cold compress or baking soda paste for comfort.
8. If swelling becomes extensive, advise medical care.
9. Notify parent/guardian of sting. Review wound care and signs of anaphylaxis and
infection.
SPIDER BITE
NIC: Emergency Care; First Aid; Heat/Cold Application; Skin Surveillance
NOTE:
_ If known allergy, follow Emergency Action Plan or physician’s order.
_ Symptoms may occur for up to 48 hours.

Section C - 58 - 02-2006
_ Student may present without knowledge that a bite has occurred.
1. HIPa
a. Observe and monitor for signs of anaphylaxis.
2. Black widow or brown recluse spider bites can be life-threatening. (For picture, go to
http://www.mayoclinic.com/health/first-aid-spider-bites/FA00048)
a. Call 911 immediately. Notify parent/guardian and administration.
b. Monitor and maintain breathing and circulation.
c. Keep bitten area lower than student’s heart level.
d. Apply cold compress to area.
e. Keep student calm and inactive.
f. Transport spider with student, if possible, for identification.
3. Other spider bites
a. Cleanse wound well thoroughly with mild antiseptic soap.
b. Apply cold compress.
c. Remove jewelry from areas distal to the bite.
d. Notify parent/guardian.
4. Future considerations:
a. Monitor for several days. Look for flu-like symptoms, rash, infection, abdominal pain or
other.
TICK BITE
NIC: First Aid; Skin Surveillance
NOTE:
_ Tape the tick to a calendar or piece of paper with date inscribed. This will assist for
later identification and provide a record of the date of the bite should symptoms
develop.
_ Deer ticks are approximately 1/8” in length. When engorged, they can be 5-7 times
the original size. More information and pictures of a deer tick are available at
http://www.ent.iastate.edu/ImageGallery/ticks/deertick.html .
1. HIPa
2. Remove tick.
a. Coat with nail polish, petroleum jelly or mineral oil and wait for tick to disengage, or apply
forceps as close to the skin as possible at the attachment site and pull tick backward with a
firm, steady pressure. Take care not to crush or squeeze tick. If the mouth or head of the
tick separate, remove as you would a splinter and refer for medical care. Do not touch the
tick without a barrier.
b. If deer tick, refer for prompt medical attention.
3. Wash wound with mild antiseptic soap and water.
4. Always notify parent/guardian of a tick bite. They will need to observe for fever and other
symptoms, which could indicate Lyme Disease. Prompt medication is needed if these
symptoms

220

occur. While Lyme Disease is the most common illness associated with ticks in Delaware,
ticks
can carry other illnesses.
NOTE:
For more information on Lyme Disease, see
http://www.cdc.gov/ncidod/dvbid/lyme/lyme_brochure.pdf.
The symptoms of Lyme Disease usually occur within 4-20 days. Symptoms include: skin
rash,
developing into reddish circle with a clearing center. Non-specific flu-like symptoms such as
headache, stiff neck, fatigue, joint and muscle aches may also appear. A blood test to detect
Lyme
Disease is available, but results will not reflect infection until 2-4 weeks after the tick
exposure.

Section C - 59 - 02-2006
Late stage symptoms of Lyme Disease include muscle aches, joint pain, and nervous system
symptoms such as numbness or pain.
5. Future considerations:
a. Monitor for Lyme Disease or other infection.
b. Encourage wearing long sleeves and high socks/footwear when in the woods, along with
the
proper use of a pesticide for humans.
PENETRATING/PUNCTURE WOUND
NIC: Bleeding Reduction: Wound; Emergency Care; First Aid; Hemorrhagic Control; Vital Signs
Monitoring; Wound Care
NOTE:
_ Penetrating wounds may be caused by such things as an impaled object (ex. pencil)
or a gunshot wound.
_ A penetrating wound to the abdomen or chest is a medical emergency.
_ There may be minimal bleeding at the site. This is not indicative of the seriousness
or extent of the injury.
1. Maintain ABCDs of emergency care. Consider possible head, neck and spinal trauma.
2. HI
3. Do not insert anything into the wound area, including topical medication.
4. Do not attempt to remove an impaled object unless the object is obviously only in the
superficial
skin layer. Stabilize the object.
5. Call 911. Notify parent/guardian and administration. Do not leave student unattended by
nonmedical
personnel.
6. Keep student calm, comfortable and NPO.
7. Monitor vital signs and level of consciousness continually.
8. Special considerations:
a. Abdomen
(1) If abdominal contents protruding from wound, cover with sterile gauze moistened
with sterile saline.
(2) Do not attempt to replace organs in abdomen.
b. Chest
(1) Do not remove object from wound. Immobilize penetrating object.
(2) Cover wound with dry sterile gauze. Make an airtight seal over gauze with plastic
wrap or aluminum foil.
(3) If sucking chest wound, cover wound with dry sterile gauze, but seal only on three
sides.
c. Extremity
(1) Monitor pulse and neuro-vascular status of any affected extremity.
9. Determine tetanus status and share with emergency responders.

221

10. Document monitoring, ongoing observations, assessment and interventions.
11. Future considerations:
a. Monitor for infection.
b. Monitor for other injuries not identified at initial evaluation.
SPLINTER
NIC: First Aid; Wound Care
1. HI
2. Wash area with mild antiseptic soap and water.
3. Removal:
a. If easily accessible and superficial, remove gently with tweezers pulling at the same angle
that the splinter went in.

Section C - 60 - 02-2006
b. If deep, do not attempt to remove.
c. Soaking affected part in warm soapy water for 20 minutes may help to loosen and soften
the
splinter for easier removal.
d. After removal, thoroughly clean the wound.
4. Determine tetanus status.
5. Indications for medical referral:
_ Large splinter
_ Deep insertion
_ Tetanus booster needed
_ Dirty wound or splinter
_ Break or suspected break of splinter during removal
6. Notify parent/guardian. Review signs/symptoms of infection and indications for seeking
medical
evaluation.

* Uphold and Graham (2003): CLINICAL GUIDELINES IN FAMILY PRACTICE, FOURTH EDITION. Gainesville:
Barmarrae Books, Inc.

Guidelines for Parent/Guardian/Relative Caregiver*

was seen in the nurse’s office today. It is recommended
that you follow the following instructions or contact your healthcare provider for more
information.

FEVER
Get extra rest and eat light meals.
Drink extra fluids every 15 to 60 minutes.
Ask your healthcare provider to recommend an over-the-counter medication to reduce the
fever. DO NOT TAKE ASPIRIN! CAN CAUSE REYES SYNDROME.
If fever persists for more than 2 days, increases to over 102º, or symptoms continue to
worsen, contact your healthcare provider.
No school until fever-free for 24 hours.
UPPER RESPIRATORY INFECTION (COLD SYMPTOMS)
Ask your healthcare provider to recommend an over-the-counter medication to ease
symptoms. DO NOT TAKE ASPIRIN! CAN CAUSE REYES SYNDROME.
Drink plenty of fluids.
Use moist air from vaporizer to help relieve congestion.
Contact your healthcare provider if:
a.) breathing difficulties occur
b.) you cough up green or yellow phlegm that has a bad odor
c.) fever persists; or
d.) you feel sicker each day instead of feeling better
NAUSEA AND VOMITING
No solids for 8 hours.
Clear liquids only (not milk) until 4 hours have passed without vomiting. Start with one
tablespoon every 10 minutes. If vomiting does not occur, double the amount every hour. If
vomiting does occur, allow the stomach to rest for 1 hour and then start again. Key is to
gradually increase the amount of fluid until taking 8 oz. every hour.

222

Resume normal diet as soon as tolerated.
Contact your healthcare provider if vomiting persists or if you suspect dehydration.
DIARRHEA
Drink water and/or sports drinks.
Resume normal diet as soon as tolerated.
Contact your healthcare provider if cramps, diarrhea or pain increases or persists or if you
suspect dehydration.
CUTS, ABRASIONS, OR MINOR BURNS
Keep the area affected clean and dry.
Change the bandage in 24 hours or sooner if it becomes soiled.
Notify your healthcare provider if signs of infection develop such as swelling, red
streaking, drainage or pus, pain, or fever.
According to school records, you have not had a tetanus booster since _______________.
If one has not been given, arrange to have the booster with your healthcare provider and
send copy of the immunization to the school nurse. If one has been received since this date,
please contact the school nurse so that your record can be updated.
BRUISES, SPRAINS OR STRAINS
Elevate and rest the affected area of the body to reduce swelling and pain.
Apply ice packs or cold compresses for 10 minutes as many times as possible to the
injured area for the first 24 hours after the injury. Wrap cold pack in a towel to minimize
the risk of frostbite to the skin.
Notify your doctor immediately if the injured area becomes grossly swollen, discolored,
cold or numb, or if the injured limb is unable to bear moderate pressure or body weight.
Ask your healthcare provider to recommend an over-the-counter medication to reduce pain
and inflammation.
Contact your family doctor or go to an emergency room if not better in 48 hours.
HEAD INJURY
You should watch for any of the following signs of severe injury, in which case you should
seek the advice of your healthcare provider as soon as possible.
a.) severe headache
b.) excessive drowsiness (unable to be awakened when asleep for 4 hours)
c.) nausea and/or vomiting
d.) doubled or blurred vision or pupils of different sizes
e.) inability to maintain erect posture, staggering, etc.
f.) unusual behavior, confusion, inappropriate anger
g.) convulsions or discharge from the ear
OTHER INSTRUCTIONS:

Nurse: Phone: Date:

Section C - 62 - 02-2006

MEDICAL REFERRAL FORM
Name Date of Birth Male Female

Injury Illness

Date Time a.m./p.m. Complaint
Where did injury occur?
How did injury occur? Collision with
Hit by Fell on/from
Other Assessment
Date of last known tetanus shot:
Part of body injured (indicated L or R for left or
right when applicable):
_
_
_
_
_
_
_

Ankle _ Eye _ Hip _ Nose
Arm _ Face _ Knee _ Scalp
Back _ Finger _ Leg _ Shoulder Comments:
Chest _ Foot _ Lip _ Stomach
Collar Bone _ Hand _ Mouth _ Tooth
Elbow _ Head _ Neck _ Wrist
Other (specify)

Nursing Intervention/Comments:

223

Parent/guardian/Relative Caregiver advised: of injury/illness Yes No
to seek medical attention: Yes No
Signature: , School Nurse Date:
Phone:
PLEASE COMPLETE AND RETURN TO SCHOOL NURSE:
Examining Physician: Date:
Diagnosis:
Treatment:
Send copy of emergency card if transporting to Emergency Room.

Section C - 63 - 02-2006
DELAWARE HEALTH
AND SOCIAL SERVICES 2004
Division of Public Health

Recommendations for Effective Management of Puncture Incidents in Schools
Objective: Adherence to the Division of Public Health's recommendations for
effective
management of puncture incidents.
Recommended Action Steps for School Personnel:
1) Ensure affected individual(s) receives prompt attention from the school
nurse.
2) Immediately report the puncture incident to your school principal. The
principal will
then be responsible for notifying your District Office, the Department of
Education, and
law enforcement officials as appropriate.
3) Review the immunization status of affected students for documentation of
hepatitis B and
tetanus containing vaccines.
4) Most school children today have received the full series of hepatitis B
vaccine. They are
not at risk and do not require hepatitis B, hepatitis B vaccine, or HBIG in the
event of a
puncture wound. School health records and the DPH Immunization Registry
are
available to schools or DPH officials to confirm that the children are
protected. Only if
the child has slipped through the cracks and is not vaccinated against
hepatitis B, should
the steps recommended for hepatitis B post-exposure management be
carried out – see
School Incident Letter sample enclosed.
5) A puncture of most types (pencil, pen, lancet, etc) ordinarily poses little if
any risk of
spread of hepatitis C or HIV because the group from which the contamination
would
have come (in a repeated stab situation) has extremely low risk to children.
Unless there

224

is a known HIV or hepatitis C case involved in the punctures, neither hepatitis
C testing
nor HIV testing is called for. Puncture wounds involving a hollow needle and
syringe
should be evaluated on a case by case basis.
6) A tetanus booster is recommended for persons if more than 5 years have
elapsed since
their last dose (DTaP, DT or Td).
7) Notify your nearest public health point of contact (see following page) of
the puncture
incident, who will then inform the Epidemiology section, Division of Public
Health. The
Division of Public Health will determine the need for intervention.
Section C - 64 - 02-2006
8) The school authority, upon advice from the Division of Public Health, will
then notify
families of affected student to inform them of blood-borne pathogen
recommendations.
*Communications should be in accordance with established school policy.
9) Please use the enclosed sample letter as a guide should your school
decide upon
widespread notification of families. Note: you should modify the sample
letter to address
your school’s specific incident as warranted.
Note: The parent/guardian/Relative Caregiver of affected students is strongly
encouraged to
consult with their children's primary health care provider to meet the
counseling, testing
and vaccine recommendations. Students should receive services from their
private
provider when possible. For those students without a primary health care
provider or
health insurance, arrangements can be made to receive the services
(vaccine and/or
immunoglobulin), free of charge, through DPH. Services may be obtained at
a DPH
clinic or in the school setting as the need dictates, and as mutually agreed
upon by DPH
and the school.
*Counseling and testing services for HIV and hepatitis B will be offered as
appropriate.
Acceptance of these services by students and families is not mandatory and
cannot be required.
Section C - 65 - 02-2006
DELAWARE HEALTH 2004

AND SOCIAL SERVICES
225

Division of Public Health

Delaware Division of Public Health (DPH)
Local Points of Contact for Puncture Incidents and Inquiries
Northern Health Services
New Castle County
Disease Prevention Team
Limestone Center
2055 Limestone Road, Suite 300
Wilmington, DE 19808
Contact: Blake Turnbull RN or Annette Rovito RN
(302) 995-8653
Southern Health Services
Kent and Sussex Counties
Georgetown State Service Center Shipley State Service Center
544 South Bedford St. Ext. 350 Virginia Avenue
Georgetown, DE 19947 Seaford, DE 19973
Contact: Sandy Norris RN Contact: Richard Tator
(302) 856-5213 (302) 628-2006
Milford State Service Center Williams State Service Center
11-13 N. Church Street 805 River Road
Milford, DE 19963 Dover, DE 19901
Contact: Jan Crouch RN Contact: Lorraine Rouse RN
(302) 422-1338 (302) 739-5305

Primary Contact:

DPH Epidemiology Branch
(302) 734-4541
DPH Immunization Program
(302) 734-4543 or 1-800-282-8672

Section C - 66 - 02-2006
School District Letterhead

2004

Delaware
[ date ]
Dear Parent:
RE: School Incident
On [ date ], a student brought a concealed sharp object to school. Several
students claim they
were stuck with the device. Please discuss this incident with your child. If
your child was
involved in the incident, contact your family doctor immediately and notify
the school by the
close of the next school day. Our phone number is [ number ].
We have been in contact with the Division of Public Health. Public Health
recommends the
following steps for your child’s protection if your child was stuck:
· If your child is previously vaccinated against hepatitis B (3 doses) NO
treatment is
necessary for protection against hepatitis B infection.
226

· If your child is not vaccinated against hepatitis B initiate hepatitis B vaccine
series (3 doses)
as soon as possible.
· If your child is a known nonresponder to hepatitis B vaccination as
confirmed by your
child’s physician, hepatitis B Immune Globulin only should be given.
· Under special circumstances, if your child is not previously vaccinated
against hepatitis B,
he/she may need hepatitis B Immune Globulin in addition to hepatitis B
vaccinations.
Please contact school nurse.
· If a known case of hepatitis C is involved in the puncture incident your child
should be
referred to a specialist for evaluation to achieve early identification of
hepatitis C infection
and to discuss treatment options from such a specialist.
· If a known HIV positive person is involved in the incident counseling and
testing for HIV
should be initiated. The HIV test should be repeated in 3 months.
· A tetanus booster is recommended for persons if more than 5 years have
elapsed since their
last dose (DTaP, DT or Td).
If you cannot obtain the above services, please contact the school nurse as
soon as possible.
Thank you for your help in this important matter.
Sincerely,
Principal
Section C - 67 - 02-2006
DELAWARE HEALTH 2004
AND SOCIAL SERVICES
Division of Public Health
Puncture Incident in a School Setting
I hereby give permission for my child
to receive the following services from the Division of Public Health. Only
those services that are
authorized by means of a check mark in the box next to the service will be
provided.
V Information pertaining to Hepatitis B and HIV (the virus that causes AIDS)
V Hepatitis B immunization
V Tetanus booster
V Hepatitis B Immune Globulin
V A blood test for previous hepatitis B exposure
V A baseline testing for anti-hepatitis C virus and a follow-up testing at 4-6
months for antiHCV and/or testing for HCV RNA at 4-6 months
V A blood test for HIV exposure ... OR
227

V All procedures noted above as recommended by the DPH
Signature of parent or legal guardian Date
For Use by Division of Public Health Staff Only
Weight Amount of HBIG Administered Site
Manufacturer Lot #
Signature Date
Section C - 68 - 02-2006

Physical Education Modification

The School Nurse assists the physical education teacher with the program
modifications for the
student who is restricted in physical education activities due to health
problems.
Recommendations from the student's licensed healthcare provider should be
obtained in writing
and based on the activities in which the student can participate.
Temporary excuses for up to three consecutive days of modification in
physical education
classes for minor illness and injury may be issued by the school nurse.
Temporary Medical Excuse for Physical Education Modification
School District School Name
Student's Name Grade
Address
Student Referred by Date
(School staff member and title)
Nature of disease or injury
Length of time for modification
Will re-examination be necessary? Date
Student is able to do the following activities:
No physical activity Moderate Calisthenics
Non-vigorous physical activity Moderate running
Vigorous physical activity
Exercises such as
Beginning (date), this student would benefit from exercises such
as , which may be taken during physical education class.
Date Name of Physician (M.D. or D.O., N.P. or School Nurse)
Address
Section C - 69 - 02-2006

III. Chronic Conditions
Section C - 70 - 02-2006

Specialized Nursing Procedures in the School Setting
Overview
The primary goal of proving skilled nursing care within the school setting is
to help the

228

student maintain the highest level of wellness and thus maximize his/her
learning
potential. When providing specialized care, the school nurse should consider
the
student’s privacy, the amount of intrusion to the student’s learning
environment and
possible disruption to the educational process. Additionally, the school nurse
should
assure that current techniques and protocols are followed.
General Guidelines
The following guidelines are applicable to all students requiring specialized
nursing
procedures or management during school hours. All specialized procedures
require a
physician’s order, which should include specific directions.
• Physician’s orders must be renewed annually (minimally) and when there
are any
changes. Examples would include, but are limited to:
gastrostomy/jejunostomy
feeding, tracheostomy suctioning, blood glucose testing, oxygen
administration and
catheterization.
• All procedures must have written parent permission, which is renewed
annually
(minimally) and when there are any changes.
• Emergency Plans from the physician should be available for any student
with a lifethreatening
condition. They should be updated and renewed annually (minimally).
• Nursing care techniques should follow evidence based practice and
protocols, as are
presented in current, accepted pediatric nursing texts* or hospital/physician
guidelines.
• Medical equipment should be used, maintained and cleaned according to
manufacturer’s directions.
• Current directions and information should be available for school nurse
substitutes.
Recommended Texts
* Pediatric Nursing Procedures
Bowden, V. & Greenberg, C. (2003). Pediatric Nursing Procedures.
Philadelphia, PA:
Lippincott.
Hootman, J. (2004). Quality Nursing Interventions in the School Setting:
Procedures,
Models, & Guidelines, 2nd Edition. Scarborough, ME: NASN.
General Nursing
229

American Academy of Pediatrics, Committee on School Health (2004). School
Health
Policy & Practice, 6th Edition. Elk Grove Village, IL: author.
Jackson A. & Vessey J. (2004). Primary Care of the Child with a Chronic
Condition, 4th
Edition. China: Mosby.
Lewis, K. & Bear, B. (2002). Manual of School Health, 2nd Edition.
Philadelphia, PA:
Saunders.
Selekman, J., editor (2006 anticipated). School Nursing: A Comprehensive
Text.
Philadelphia, PA: F.A. Davis.
Wong, D. & Hockenberry, D. (2003). Wong’s Nursing Care of Infants and
Children, 7th
Edition. St. Louis, MO: Mosby
Section C - 71 - 02-2006

Parent/Guardian/Relative Caregiver's Request Form for
School to Provide
Specialized Nursing Treatment or Procedure
Permission and directions should be renewed at the start of each school year.
Child's Name Phone No.
Physician's Name Phone No.
Address
I (We) request the following health care procedure to be done:
This procedure has been approved by the child's licensed healthcare
provider,
(Physician's Name) .* I (We) will notify the school
immediately if there is a change in licensed healthcare provider, health
status of child
(Child's Name) , or change in procedures.
I understand the school nurse may need to speak with the prescribing
healthcare provider.
I grant permission for the sharing of information relative to my child’s
procedure and the
related diagnosis.
Signature of Parent/guardian/Relative Caregiver(s)
Address
Home Phone Work Phone
Attach document to this effect.

Section C - 72 - 02-2006
Date

Physician's Approval of Procedure
The licensed healthcare provider will approve or authorize the procedure that is to
be used in the
school. The authorization will include the following information:
230

Name of Child Birth Date
Physical condition for which procedure is authorized
Name of procedure to be performed
Precautions, possible untoward reactions, and interventions
Time schedule and/or indication for the procedure
Physician's Signature
Address
Phone Number Date

Section C - 73 - 02-2006
Student’s Name
Individual Daily Prescribed Medication/Treatment
Date Time Medication/Treatment Comments/Reactions Initials*
*
Initials Full Name Initials Full Name
Initials Full Name Initials Full Name
Section C - 74 - 02-2006
Emergency Healthcare Plan

Name: DOB:
Teacher: Grade:
Medical Condition:
Symptoms of Condition:
Action/Treatment:
Parent/Guardian/Relative Caregiver: Phone:
Parent/Guardian/Relative Caregiver: Phone:
Physician: Phone:
Emergency Contact: Phone:
If symptoms of health problems above occur, the school nurse will assess the student and
institute the
prescribed action/treatment. The school nurse or designee will contact the
parent/guardian/Relative Caregiver
of the student. If a parent/guardian/Relative Caregiver cannot be reached, the emergency
contact person will be
called. Emergency personnel may be given a copy of this form.
Parent/Guardian/Relative Caregiver Signature: Date:
Physician Signature: Date:
Place
Student’s
Picture
Here

Section C - 75 - 02-2006

Special Needs Alert Program (SNAP)
Prepare Before a 911 Call

What is SNAP? SNAP identifies children with special health care needs in the
community for
emergency medical services (EMS) providers. SNAP encourages families to meet
with EMS staff in
their home before they have to make a 911 call. The program educates EMS
providers about the
unique needs of the child. Any child (0-21 years) with special emergency care needs
may enroll. No

231

family will be excluded if they feel they would benefit from SNAP. Participation is
strictly on a
voluntary basis. You may cancel enrollment at anytime.
How to enroll a child
1. Call the Emergency Medical Services for Children (EMSC) Office at 302-744-5415
and ask to
enroll in the SNAP program or you may also go to:
http://www.familyvoices.org/st/DE.htm to
download the forms in English or Spanish.
2. Complete the following documents:
_ Enrollment Form
_ Consent Form signed by parent or guardian
_ Emergency Information Form signed by the child’s physician or licensed
healthcare provider.
3. Mail or fax completed SNAP documents to:
Special Needs Alert Program
Attention: Beth MacDonald, SNAP Coordinator
Office of Emergency Medical Services
Blue Hen Corporate Center
655 South Bay Road, Suite 4-H
Dover, DE 19901
4. EMSC will contact the local county EMS agency and complete the enrollment
process.
A SNAP call to 911
• The family calls 911. Their address is flagged in the 911 system when the call is
placed from
the home phone. All responding units are notified that this is a SNAP child. The
emergency
medical responders can review the child’s special information and prepare for
arrival in the
home.
• When an emergency call is placed from school, you may identify the child as a
SNAP child.
• SNAP children are identified by county according to their home address.
• EMS providers are able to be more prepared to provide special care for children in
the
program.
For questions or more information contact Beth MacDonald at:
Phone: (302) 744-5415
Fax: (302) 744-5429
E-mail: [email protected]
DELAWARE HEALTH AND
SOCIAL SERVICES
Division of Public Health

This project was supported in part by grant number 1 H33 MC00112-03 from the
Department of Health and
Human Services, Health Resources and Services Administration, Maternal and Child Health
Bureau.

Section C - 76 - 02-2006

Allergy - Food
I. General Guidelines
232

A. A food allergy is the immune system’s abnormal response to an ingested food or
food
substance. The ingested allergen causes the release of histamines into the body
resulting in
an allergic reaction, possibly anaphylaxis.
B. Most common foods causing allergic reactions:
• peanuts
• nuts
• wheat
• soy
• milk
• eggs
• any food containing the protein of one of the above foods
II. Procedures
A. Preventative Measures:
• Notify parent/guardian/Relative Caregiver of other students in classroom of the
student
with a food allergy specifying the known food allergy and other foods containing the
allergen (see following sample letter).
• Encourage students with a food allergy to bring their own lunches and snacks.
• Consider designating a table in the cafeteria where students eating the identified
food(s)
may not sit.
• Students in the classroom with a child with a food allergy, who eat the food
causing the
allergic reaction while at school, must thoroughly wash their hands before returning
to
the classroom.
• Train school staff who contacts the student with a food allergy about food allergies
and
preventative measures as well as the appropriate response to an allergic reaction
(i.e.,
cafeteria staff, substitute teachers, office and custodial staff).
• Students with a food allergy will need a doctor’s note if food substitutions are
need in the
cafeteria.
B. Symptoms and Treatment:
• Follow protocols for managing Anaphylaxis.
• Have an Emergency Health Care Plan for each student with a food allergy.
• Common Warning Signs and Symptoms:
o complaint of tingling, itchiness, or metallic taste in the mouth
o hives
o difficult breathing
o swelling and/or itching of the mouth and throat area
o diarrhea or vomiting
o cramps and stomach pain
o paleness and drop in blood pressure
o loss of consciousness
III. References

233

Gaudreau, J. (2000) 1. The Challenge of Making the School Environment Safe for
Children with
Food Allergies. Journal of School Nursing, 16(2), 5-10.
The Food Allergy Network
10400 Eaton Place, Suite 107
Fairfax, VA 22030-2208
www.foodallergy.org

Section C - 77 - 02-2006

Dear Parent/Guardian:
This year, your child’s class has a child with a life-threatening food allergy to
__________. I
am notifying parents/guardians/Relative Caregivers so that we can ensure a safe
and worry-free year
for the student and his/her family.
It is important that you understand an allergic reaction can occur from any contact
with the food
that causes the allergy. The child with a food allergy can be in danger if food is
spilled onto his/her
snack or lunch, or if the food is transferred unknowingly to an object the child may
touch.
Attached is a list of foods that may contain the food to which this child has an
allergy. Please
try to avoid sending in any foods from that list. If your child eats any of the foods
from the list during
the school day, please remind him/her that it is very important to wash his/her
hands thoroughly.
There will be a table in the cafeteria where no one eating the food causing the
allergy will be
permitted to sit. If your child brings food from the list or chooses those foods from
the cafeteria
menu, he/she will need to sit away from the special table.
Let’s help our children to have a safe, happy and healthy school. If you have
questions or
concerns, please contact me. Thank you for your help.
Sincerely,
(School Nurse)
“Allergy-Food” developed 4-2001

Section C - 78 - 02-2006

Allergy - Latex

I. General Guidelines
A. What is latex?
Natural latex is produced from the rubber tree Hevea basiliensis. More than 400
medical
products contain latex including: stethoscopes, latex gloves, surgical masks,
adhesive
bandages, tape, syringe plungers, blood pressure cuffs, catheters and tourniquets.
Many
household items also contain latex such as balloons, dishwashing gloves, nipples for
baby
234

bottles and pacifiers, tires, bicycle handlebar grips, condoms, waistbands in clothing
and
swimming goggles. In addition, school items include: rubber bands, erasers, rubber
balls
and playground/track surfaces. It is important to know that many of these products
contain both latex and other chemicals. An individual may have a reaction to either
the
latex or the chemicals.
B. How latex allergy develops
The protein in latex acts as a sensitizer and the amount needed to cause a reaction
varies
from individual to individual. Those individuals that are at higher risk of becoming
sensitized include:
• persons with history of multiple allergic conditions particularly to potatoes,
bananas,
papaya, tomatoes, kiwi, avocado and chestnuts
• persons who have had multiple surgeries
• persons who frequently use latex gloves or other latex-containing products.
Latex protein adheres to the powder in powdered latex gloves and each time these
are
donned and removed, the protein is released in the air and inhaled causing
exposure.
Washing hands before using gloves is important since any dirt can cause a possible
irritation and skin breakdown, increasing the risk of latex exposure. Prior hand
washing
removes oil-based ointments, gels and products that can combine with the proteins
and
increase the potential of exposure. Likewise, it is essential to wash your hands
thoroughly after removing the latex gloves since the proteins may have adhered to
your
skin. If hand lotion is applied prior to washing the hands then the proteins will more
tightly bond to the skin.
C. Types of skin irritation
Three types of skin irritation are associated with use of latex.
1. Irritant contact dermatitis
This is characterized by dry, itchy, irritated skin. It is not a true allergy and
develops over time. It can be caused by repeated hand washing, inconsistent
drying, use of cleaners and powders added to gloves.
2. Chemical sensitivity dermatitis
This is characterized as poison ivy-like blisters that appear 24-48 hours after
contact. This is not caused by the latex, but from the chemicals used to process it.
3. Latex allergy (immediate hypersensitivity)
This is characterized by itchy eyes and scalp, scratchy throat and respiratory
involvement. Hives and redness may result. Symptoms will usually occur within
minutes of exposure.
Expect sensitization if the following symptoms develop immediately after exposure
to
latex:
• redness
• hives (urticaria)
235

• runny nose (rhinorrhea)
• scratchy throat
• wheezing or asthma

Section C - 79 - 02-2006

• itching at point of contact, eyes, or nose
• collapse or shock
• if anaphylaxis refer to protocols
D. How diagnosis is made
A licensed healthcare provider will take a detailed medical history combined with
testing.
The doctor may order a latex sensitivity test or a food allergy test since several food
allergies are associated with latex sensitivity.
II. Procedures
A. Preventive measures and treatments
There presently is no cure for latex allergy.
• Prevention and avoidance along with treatment of symptoms are the current
options.
Although there are some medications that can reduce allergic symptoms, the most
effective approach is avoidance.
• It is important to use special precautions at school, work, home and when
receiving
medical and dental care. Several products are produced with synthetic latex and
they
do not release the proteins that can cause an allergic reaction.
• A person who is diagnosed with latex allergy should wear a medical alert bracelet
to
identify their sensitivity and should notify their employer, dentist and licensed
healthcare providers.
• Other school personnel should be aware of the latex allergy on a “need to know”
basis; i.e., cafeteria and food service personnel, teachers and custodians.
• The school nurse will want to order non-powdered, non-latex gloves to use for
latex
sensitive individuals.
B. Emergency Reaction
Refer to protocols for managing anaphylaxis.
III. References
A. Resources.
The National Institute of Occupational Safety and Health (NIOSH) can provide a list
of
latex safe products at their website at www.cdc.gov/niosh/homepage.html.
LabCorp (Laboratory Corporation of America). Latex Sensitivity-Could it Affect You?
www.LabCorp.com.
“Allergy-Latex” developed 4-2001

Section C - 80 - 02-2006

Asthma

Description
Asthma is a chronic inflammation of the airways (bronchioles). People with asthma
have hyperresponsive
airways that may over-react to specific asthma triggers for that person. The
inflammation
236

of the airway leads to:
1. edema of the mucous membranes lining the bronchioles
2. accumulation of mucous secretions
3. constriction of the circular muscle in the middle layer of the bronchioles, which
decreases the
diameter of the airway
Asthma affects nearly 20 million Americans and is the most common chronic
condition among
children and is the number one cause of school absenteeism among children 1.
Diagnosis is
determined by a licensed healthcare provider
(http://www.nhlbi.nih.gov/health/dci/Diseases/Asthma/Asthma_Diagnosis.html).
Effective asthma
management lessens airway inflammation, hyper-responsiveness of the airways,
symptoms, and the
need for frequent use of bronchodilators, by decreasing or eliminating exposure to
stimuli that
provoke an asthma episode and/or by taking daily anti-inflammatory medication.
Etiology
Asthma is a complex multigenetic disease with a strong environmental component.
There is also a
genetic component to airway hyper-responsiveness 2. Asthma triggers can be
allergens (substances
that cause allergies such as dust mites, pollens, molds, pet dander, shellfish, nuts,
etc.), irritants in the
air (cigarette smoke, wood burning, smoke, paint, perfume, pollution, household
sprays, gasoline
fumes, etc.), respiratory infections (colds, flu, sore throats, sinus infections),
exercise (activities that
increase respirations), strong emotions (anger, fear, crying or laughing,
gastroesophageal reflux
disease), weather-related factors (cold, heat, humidity, sudden changes, etc.) and
even some
medications (aspirin, penicillin, etc.). Each asthma episode can be unique, therefore,
it is important to
investigate and record the triggers and responses of each episode. The National
Heart, Lung and
Blood Institute offers a fact sheet on What Causes Asthma? at
http://www.nhlbi.nih.gov/health/dci/Diseases/Asthma/Asthma_Causes.html.
Symptoms
The most common asthma symptoms are:
1. wheezing
2. shortness of breath
3. coughing
4. chest tightness
Other symptoms include anxiety and/or agitation, cyanosis (lips or nailbeds), nasal
flaring, tripod
posture, labored breathing with use of accessory muscles, stridor, decreased breath
sounds, crackles,

237

difficulty speaking in sentences, and decreased peak expiratory flow rate. Not all
people with asthma
may exhibit all of these symptoms.
It should be noted that the absence of wheezing upon auscultation may be
symptomatic of severe
respiratory depression.
1
2

http://www.aafa.org/display.cfm?id=9&sub=42
http://www.clevelandclinicmeded.com/diseasemanagement/pulmonary/asthma/asthma.htm

Section C - 81 - 02-2006

Preventative Measures
The person with asthma should have a thorough physical examination done by their
healthcare
provider. Additional testing may include lung function test, chest x-rays and/or sinus
x-rays. The
primary care provider may refer to an allergist, pulmonary specialist or internist.
Once a diagnosis is
made, the person should:
1. Know his/her asthma triggers and try to minimize exposure
2. Take the prescribed medication, which will likely include:
a. Maintenance medication, which is taken daily to decrease inflammation and limit
the
production of mucous
1. Inhaled corticosteroids
2. Cromolyn and Nedocromil
3. Theophylline, Sustained Release
4. Leukotriene Modifiers
5. Long-Acting Beta Agonists
b. Quick relief medication for prompt treatment of acute airflow obstruction and its
accompanying symptoms
1. Short-Acting Beta Agonists
2. Systemic Corticosteroids
3. Monitor the asthma through the use of a peak flow meter. A peak flow meter is a
device that
measures expiratory air flow. It can provide the earliest signs that an asthma is
changing and
determine which medication to take, how much to take, when to take it, when to call
your
doctor or to seek emergency care.
4. Know what to do when asthma symptoms continue to worsen. (Refer to the
Asthma Action
Plan.)
5. Follow an Asthma Action Plan, which is developed by the doctor,
parent/guardian/Relative
Caregiver and student.
Nursing Assessment and Intervention
Routine Procedures/Equipment
1. Review Asthma Action Plan with student at the beginning of each year.
2. Determine if the student knows his/her asthma triggers.
3. Have student demonstrate use of their peak flow meter and recording their peak
expiratory
238

flow. (Refer to use of Peak Flow Meter at
http://www.lungusa.org/site/pp.asp?c=dvLUK9O0E&b=22586)
4. Review prescribed medications. Assess student’s technique in using a MeteredDose Inhaler
and Spacer and/or Nebulizer. (Refer to www.aanma.org/pdf/MaximizeMist.pdf for
information on inhalers, their action, use and cleaning)
5. Maintain accurate records on each student with asthma.
6. Inform students and teachers of their responsibilities to assure adequate care
within the
school setting.
7. Contact a parent/guardian/Relative Caregiver for changes in a student’s asthma
status,
including changes in peak flow readings, increased use of rescue inhaler and/or
nebulizer, or
changes in triggers that may result in an asthmatic concern.
8. Consider facilitating student self-administration for emergency inhaler. (Refer to
regulation
612.3.11.)
9. Clean inhalers, spacers and nebulizer routinely as directed.
Emergency Equipment/procedures
1. Assess breathing status:

Section C - 82 - 02-2006

a. Visual appearance (color, nasal flaring, intercostals retractions, chest
hyperinflation, use
of accessory muscles)
b. Auscultation of lungs with stethoscope (air exchange on inspiration and
expiration,
wheezing, etc.)
c. Peak Flow Meter (compare to student’s best)
d. Vital signs, including respiratory rate
e. Level of consciousness
2. Follow Asthma Action Plan.
3. Give quick relief medication, as prescribed.
4. Monitor vital signs and respirations.
5. Position student so that he/she is comfortable – do not force to lie flat.
6. Remain calm and speak to student in a reassuring voice. Help the student with
relaxation
techniques. Asthma can be exacerbated by anxiety and stress.
7. Repeat second dose of medication if stated in doctor’s orders.
8. If the asthma episode is secondary to a severe allergic reaction, be prepared to
administer
epinephrine per standing or individual PRN orders.
9. Continue to monitor respiratory status.
10. Do not give fluids if in severe distress or chance of impending collapse.
11. If no improvement or respiratory collapse seems imminent, call 911. Clinical
signs and
symptoms of impending respiratory failure are: diminished level of consciousness,
pallor/central cyanosis, recurrent acute episodes over a short period, severe
respiratory

239

distress or exhaustion, inspiratory wheezing/silent chest, tachypnea >150% of
normal
respiratory rate, peak flow 25-50% of personal best, heart rate >120/min
(dependent upon
age). Bradycardia (low heart rate) immediately precedes respiratory failure.
12. Notify parent/guardian/Relative Caregiver with or without EMS involvement.
Role of the School Nurse
“An active partnership among patients, families, and healthcare providers is the
foundation of successful asthma management.”1
The school nurse plays a vital role in the management of asthma in the school
setting as an educator,
healthcare provider, leader, liaison, promoter and resource person. Coordination of
these various
roles must occur in order to be productive and effective.
The school nurse is an educator of the students as well as families, faculty and staff.
He/she must
have up-to-date information, be able to assess what is already known, teach correct
techniques, be
able to problem-solve, keep the appropriate people informed, break down
instruction in small steps,
use appropriate language in dealing with particular ages, and be able to evaluate
what he/she has
taught.
Perhaps the most important role of the school nurse is as a provider of health care.
From the
identification of students who have asthma, the development of an Asthma Action
Plan, the keeping
of accurate records, the administration of medication, to the emergency care
measures provided
during an asthma episode, the school nurse works with the student one-on-one on a
daily basis.
The school nurse is a leader. In this role it is important to have up-to-date
information and knowledge
of current research and developments in asthma control. People look to the school
nurse as a role
1

http://www.mainehealth.org/mh_about/

Section C - 83 - 02-2006
model and advocate for students, their care and community issues such as Clean
Air, a safe environment, no smoking
policies and pollution control.
The school nurse serves as a liaison. The student’s case management involves
communication with the student’s
parent/guardian/Relative Caregiver, healthcare provider, educational staff, support
staff such as bus drivers, and
community agencies.
The school nurse must be a promoter of health and a healthy school environment in
order to increase awareness of what
constitutes the best learning environment and conditions for an optimum learning
experience. Normal activity levels for
students with asthma are encouraged and promoted.
240

Lastly, the school nurse serves as a resource person. He/she must be able to answer
questions from students, families,
healthcare providers, teachers, staff and the administration he/she serves. In order
to provide accurate and current
information, the school nurse must be aware of community resources that are
available for different ages and groups.
Resources
American Academy of Allergy Asthma and Immunology (AAAAI),
http://www.aaaai.org
American Lung Association (ALA), http://www.lungusa.org
Asthma Allergy Network Mothers of Asthmatics (AANMA), http://www.aanma.org
Asthma and Allergy Foundation of America (AAFA), http://www.aafa.org
Centers for Disease Control and Prevention (CDC) Healthy Youth! Asthma,
http://www.cdc.gov/HealthyYouth/asthma/index.htm
Maine Health, http://www.mainehealth.org
Medical Society of Delaware, http://www.msdhub/com, Clinical Guidelines for
Asthma
National Asthma Education and Prevention Program, National Heart, Lung, and
Blood Institute, http://www.nhlbi.nih.gov
Epi-Pen and Epi-Pen Jr. manufactured by Dey, Meridian Medical Technologies, Inc.,
http://www.epipen.com/pdf/PatientInsert.pdf
References
American Lung Association of Delaware, http://www.lungusa.org
Kavuru, M.D.; Mani S.; David M. Lang, M.D.; Serpil C. Erzurum. Asthma, The
Cleveland Clinic, Published January 22,
2003, Revised February 28, 2005.
http://www.clevelandclinicmeded.com/diseasemanagement/pulmonary/asthma/asth
ma.htm
Guidelines for the Diagnosis and Management of Asthma, NIH Publication No. 974051, July 1997, National Institutes of
Health, National Heart, Lung and Blood Institute.
NASN. Issue Brief, Role of the School Nurse, (2002).
http://www.nasn.org/briefs/2002briefrole.htm.
Update to Nurses: Partners in Asthma Care, NIH Publication No. 95-3308, October
1998, National Institutes of Health,
National Heart, Lung and Blood Institute.
http://www.nhlbi.nih.gov/health/prof/lung/asthma/nurs_upd.pdf.

7/2005 Reviewed by Deborah Brown, Director of Programs & Advocacy,
American Lung Association of
Delaware.
Section C - 84 - 02-2006

Asthma Action Plan

General Information:
_ Name
_ Emergency contact Phone numbers
_ Physician/Health Care Provider Phone numbers
_ Physician Signature Date

_ Mild Intermittent _ Moderate Persistent _ Colds _ Smoke _ Weather 1. Pre-medication (how much and
when)
_ Mild Persistent _ Severe Persistent _ Exercise _ Dust _ Air pollution

241

_ Animals _ Food 2. Exercise modifications
_ Other

Green Zone: Doing Well Peak Flow Meter Personal Best =
Symptoms Control Medications
_ Breathing is good Medicine How Much to Take When To Take It
_ No cough or wheeze
_ Can work and play
_ Sleeps all night
Peak Flow Meter
More than 80% of personal best or ________
Yellow Zone: Getting Worse Contact Physician if using quick relief more than 2 times
per week.
Symptoms Continue control medicines and add:
_ Some problems breathing Medicine How Much to Take When To Take it
_ Cough, wheeze or chest tight
_ Problems working or playing
_ Wake at night
Peak Flow Meter
Between 50 to 80% of personal best or
to
IF your symptoms (and peak flow, is used)
return to Green Zone after one hour of the
quick relief treatment, THEN
o Take quick-relief medication every
4 hours for 1 to 2 days
o Change your long-term control medicines
by
o Contact your physician for follow-up care
IF your symptoms (and peak flow, if used)
DO NOT return to the GREEN ZONE after
1 hour of the quick relief treatment, THEN
o Take quick-relief treatment again
o Change your long-term control medicines
by
o Call your physician/Health Care Provider
within hours of
modifying your medication routine
Red Zone: Medical Alert Ambulance/Emergency Phone Number:
Symptoms Continue control medicines and add:
_ Lots of problems breathing Medicine How Much to Take When To Take It
_ Cannot work or play
_ Getting worse instead of better
_ Medicine is not helping
Peak Flow Meter
Between 0 to 50% of personal best or
to
Go to the hospital or call for an ambulance if
o Still in the red zone after 15 minutes
o If you have not been able to reach your
physician/health care provider for help
o
Call an ambulance immediately if the
following danger signs are present
o Trouble walking/talking due to shortness
of breath

242

o Lips or fingernails are blue

Section C - 85 - 02-2006

Attention-Deficit/Hyperactivity Disorder (ADHD)
Description
Three to seven percent of school-aged children have been identified with AttentionDeficit/Hyperactivity Disorder (ADHD) [Barkley, 2000]. Until relatively recently, it
was believed
that children outgrew ADHD in adolescence as hyperactivity often diminishes during
teen years.
However, it is now known ADHD nearly always persists from childhood through
adolescence and
that many symptoms continue into adulthood. Current research reflects rates of 34% among adults.
Etiology
ADHD is a brain-based condition. Research is underway to better define the areas
and pathways that
are involved. Indications from more than 20 genetic studies are ADHD tends to run
in families and
that the patterns of transmission are to a large extent genetic. This is a complex
disorder and is the
result of multiple interacting genes. Parenting styles may influence the condition,
but are not the
causative factor.
Symptoms
Diagnostic criteria for ADHD are separated into three categories; inattention,
hyperactivity and
impulsivity. Children with ADHD may exhibit many of these behaviors within the
classroom and/or
home environment. Some children exhibit behaviors in only one of these categories,
while others
may exhibit behaviors in all categories. School nurses need to recognize these
behaviors and how
they may interfere with a child’s progress within a school setting.
The three types of ADHD are: (1) predominantly inattentive type; (2) predominantly
hyperactiveimpulsive
type; and (3) combined type. The CDC website provides an overview of what is
AttentionDeficit/Hyperactivity Disorder (ADHD) at http://www.cdc.gov/ncbddd/adhd/what.htm.
Diagnostic
criteria are available at http://www.cdc.gov/ncbddd/adhd/symptom.htm.
Nursing Assessment and Intervention
ADHD in children often requires a comprehensive approach to treatment called
“multimodal” and
may include:
• Parent and child education about diagnosis and treatment
• Specific behavior management techniques
• Medication
• Appropriate supports and school programming
Role of the School Nurse for the Student with ADHD

243

The NASN has developed seven role concepts relative to working with children with
ADHD. It is the
professional school nurse that incorporates these standards while working with the
family and the
child with ADHD. The school system may be the first to identify symptoms that
necessitate
evaluation by a healthcare provider. The school nurse should not diagnose or
recommend
medication, but is responsible for making appropriate referrals.

Section C - 86 - 02-2006

As a provider of direct health care, the school nurse must have a sound knowledge
of ADHD. Many
of these children are “risk takers”, which may result in frequent injuries from
playground mishaps to
car accidents. School nurses provide care not only to the physical injuries of these
children, but also
to their emotional needs as they often make hurried and careless mistakes.
As a leader, the school nurse’s role extends beyond the classroom. The nurse is
often the only health
professional in the educational setting. Educating staff members and students about
ADHD is
necessary to assure that all persons have a sound understanding of this condition.
Communication
should also include the availability of outreach programs and support groups within
the community to
be a part of the educational understanding of ADHD.
The school nurse needs to have a sound knowledge of the legal aspects of public
laws relating to
education especially The Individual with Disabilities Act (IDEA) and Section 504 of
the Vocational
Rehabilitation Act of 1973 (Public Law 93-112; Public Law 101-476). These laws
provide the basis
for the child’s right to a yearly individual education plan and may also reflect on the
child’s
individualized healthcare plan. Screening updates, medication changes, and input
from the student
and family should also formulate the student’s health plan.
As a client teacher for a healthy school environment, the school nurse’s
responsibility is to create an
environment to achieve optimal wellness within the school community. Selecting
educational
materials for school libraries and media centers can assist staff and students on
recognizing signs and
symptoms of ADHD and medical, educational and psychological resources that are
available to these
students. Activating public resources for ADHD such as Children and Adults with
Attention Deficit
Disorder (CHADD) and local physicians and nurses who are experts on this subject
helps to educate
the community on ADHD.
244

The school nurse can enhance care by maintaining current knowledge of ADHD
literature and
research. Grants for research can contribute to the future of school nursing and
supplies direction for
the care of children in the school setting.
As the health care expert within the school system, the school nurse takes a
leadership role in the
development and evaluation of school health policies, making them appropriate for
a child with
ADHD or any other health condition. The school nurse represents all children by
participating in and
providing leadership to the coordinated school health program, crises/disaster
management teams, and
school health advisory councils.
The school nurse is a liaison who communicates with the family through telephone
calls, assures
them with written communication and serves as a representative of the school
community. Learning
successful techniques used in other school settings can assist the school nurse. The
school nurse also
communicates with community health providers and community healthcare
agencies while ensuring
appropriate confidentiality, developing community partnerships and serving on
community coalitions
to promote the health of the community. Participation in state and national
organizations serves to
provide collaboration, personal growth and knowledge of national and state
standards.
Resources
Attention Deficit Information Network, Inc.
475 Hillside Avenue
Needham, MA 02194
Tel: (617) 455-9895
Fax: (617) 455-5466

Section C - 87 - 02-2006

CHADD (Children and Adults with Attention Deficit Disorder)
National Office
8181 Professional Place, Suite 150
Landover, MD 20785
Internet: http://www.chadd.org
National Attention Deficit Disorder Association
P. O. Box 972
Mentor, OH 44061
Tel: (216) 350-9595 or 800-487-2282
Fax: (313) 769-6729
National Resource Center on AD/HD, a CHADD program funded by CDC,
http://www.help4adhd.org/
References
Barkley, R.A. (2000). Taking charge of ADHD

245

Centers for Disease Control and Prevention: Attention-Deficit/Hyperactivity Disorder
(ADHD).
Retrieved at http://www.cdc.gov/ncbddd/adhd on 7-25-05.
Children and Adults with Attention Deficit Disorder (CHADD), Retrieved on 7-15-05.
Conners, K. & Jett, J. (1999). ADHD in adults and children: The latest treatments and
strategies.
Public Law 93-112 (1973). The Vocational Rehabilitation Act, Section 504, 29 USC,
45CFR,
Washington, DC: US Government Printing Office.
Public Law 101-476 (1990). The Individuals with Disabilities Education Act [IDEA] of
1990.
Washington, DC: US Government Printing Office.
Wender, P. ADHD (2000). Attention deficit hyperactivity disorder in children and
adults.

Section C - 88 - 02-2006

Diabetes—Hypoglycemia/Hyperglycemia Reaction
Hypoglycemic Reaction (Insulin Shock)

A. Hypoglycemic reactions (insulin reactions) should be treated according to current
nursing and
medical recommendations.
B. Periodic communication should be maintained between the school nurse, the
attending licensed
healthcare provider, and parent/guardian/Relative Caregiver of the students with
diabetes to
determine current condition and treatment regimen.
C. Students taking insulin may require care for hypoglycemic reactions resulting
from:
1. Not enough food or delayed meal
2. Too much exercise
3. Nervous tension
4. Illness
5. Too large a dose of insulin
D. Hypoglycemic reactions occur most frequently
1. Just before meals
2. After strenuous exercises
E. Use of self-testing machine
1. Student may use with parent/guardian/Relative Caregiver or licensed healthcare
provider
permission
F. Procedures
1. Give 15 grams of simple fast acting carbohydrates*:
a. 4-6 ounces of any kind of juice, except tomato or grapefruit
b. 8 ounces of skim or low fat milk
c. One teaspoon sugar packets (3 teaspoons needed)
d. Glucose tablets/get 4 tablets or 1 gel tube
e. Coke (8 ounces regular soda)
f. Raisins (small box or 2 tablespoons)
g. A tube of cake icing, preferably gel
h. Glucagon injection (if ordered by physician)
246

2. Observe student closely for improvement, check blood glucose in about 10-15
minutes.
3. If student shows no improvement, repeat previous steps, or if becomes
unconscious,
immediately call 911 for transport to hospital. Follow procedure for shock:
a. Keep warm
b. Elevate feet
c. Maintain patent airway
4. Notify parent/guardian/Relative Caregiver, physician, and administration.
*If unsure of insulin shock or hyperglycemia, the carbohydrates will not worsen
situation
(condition); so if in doubt, give carbohydrate.

Hyperglycemic Reaction

A. Hyperglycemic (>180 mg/dl) reactions have a slow onset due to insufficient
insulin, too little
activity, or too much food. Emotional stress, illness, and injury can also be major
factors.
Sometimes a hyperglycemic reaction is due to aggressive treatment of a low blood
sugar
episode.
B. Procedures
1. Exercise is an excellent treatment. If the blood sugar is greater than 300 mg/dl or
ketones
are present, DO NOT RECOMMEND EXERCISE.

Section C - 89 - 02-2006

2. Call parent/guardian/Relative Caregiver or physician for treatment with insulin if
no
protocol has been established.
3. Give fluids (sugar-free) if alert and oriented.
4. Review daily routine, meal plan, exercise regime, insulin, history of recent trauma
or
illness.
C. Diabetic Ketoacidosis (DKA) is more common in newly diagnosed students, or in
students
wearing an insulin pump. It may be due to illness, poor control, lack of knowledge
base, or
mechanical problems with the pump.
1. A student does not have to be in coma when DKA is present to be in trouble.
2. Immediate medical treatment is necessary.
3. Hospitalization is usually required for stabilization.

Section C - 90 - 02-2006

What to do in an Emergency
Hypoglycemia

Signs and symptoms Treatment for reactions
• Excess sweating • 4-6 oz. fruit juice
• Faintness • 4-6 oz. regular (sugared) soda
• Quickened heartbeat • 3-4 glucose tablets (4 grams each)
• Confusion • tube of glucose gel (15 or 30 gm)
• Trembling • 3-4 packets of table sugar
247












Sudden onset of headache • 8 ounces skim or low fat milk
Clammy
Impaired vision
Sudden onset of hunger
Drowsiness
Irritability
Personality change
Convulsions
Unconsciousness
Coma

Hyperglycemia

Signs and symptoms Treatment for reactions
• Blood glucose >180 mg/dl • Review daily routine
• Increased thirst (meal plan, exercise,
• Increased urination medication, monitoring)
• Large amounts of glucose in blood or urine
• Blurry vision
• Drowsiness
• Slow-healing cuts
• Headache

Diabetic Ketoacidosis

Signs and symptoms Treatment for reactions
• Blood glucose >240 mg/dl • Call licensed healthcare provider to
and ketones in urine determine need for more
• Fruity breath insulin, fluids, or
• Abdominal pains hospitalization
• Generalized aches/weakness
• Heavy labored breathing
• Loss of appetite
• Nausea and vomiting
Section C - 91 - 02-2006
Hypoglycemia Diabetic Acidosis
Cause: Delay in eating or not Very little or no insulin
eating enough food Vomiting
Excess insulin Febrile illness
Nervous/emotional stress Mechanical insulin pump
Excess exercise failure or delivery issue
Onset: Rapid Quickly if cause is due to
interruption in insulin pump
delivery
Symptoms: Pallor-excessive perspiration, Increased thirst and urination
hunger, headache, blurry Loss of appetite
vision, irritability, Nausea, vomiting
inability to concentrate, May have fruity breath
inattentiveness, drowsiness,
248

poor coordination, nausea,
trembling, abdominal pain
Observations: Pale, moist skin, full rapid Red, dry skin, soft eyeballs,
pulse, dilated pupils, rising Deep and rapid breathing,
blood pressure Falling blood pressure
Treatment: Give 15 grams of carbohydrate Needs insulin and fluid.
for example: Should not be in school.
4-6 ounces fruit juice
6-8 ounces regular soda
8 ounces skim or low fat milk
4 glucose tablets
1 tube glucose gel
Glucagon (if ordered by physician)
(If in doubt about reaction, it is safest to treat as a hypoglycemic episode.)
General Advice (Juvenile Diabetes Research Foundation)
1. Watch student's class performance before lunch.
2. Don't assign student to last lunch period.
3. Don't assign physical exercise just before lunch.
4. If the student needs a mid-morning snack, help him/her be as
inconspicuous as
possible.
5. Teachers and nurses should keep sugar readily available.
6. Many diabetic students take extra sugar or nourishment before planned
strenuous
exercise. Help them to avoid reactions.
8-2005 Reviewed by Pat Wagner, RN, CDE on behalf of Division of Public Health, Diabetes
Prevention and
Control Program.

Section C - 92 - 02-2006

Hearing Aid
Recommended Protocol for Monitoring Students with a Hearing Aid
Description
Hearing aids amplify sounds and improve hearing. A hearing aid has a significant
impact on the
child’s classroom participation, peer socialization, and overall educational
achievement. One that is
improperly used, malfunctioning, ill fitting or poorly equipped can compromise the
child’s wellbeing.
Preventative Measures
It is recommended that the student have a weekly hearing aid check by the school
nurse, teacher,
speech pathologist, or other appointed school professional.
Nursing Assessment and Intervention
Maintain a list of students with hearing aids that includes:
1. Student: name, grade, classroom
2. Instrument: make, model, battery number, receiver number (if applicable), and
ear to which aid is
fitted
249

3. Date of last audiologic and hearing aid evaluation
4. Who is responsible for upkeep and maintenance (parent/guardian/Relative
Caregiver, Division of
Public Health, or private facility)
5. Specific cleaning instructions from parent/guardian/Relative Caregiver or
manufacturer
6. Note: Urge parent/guardian/Relative Caregiver to change the batteries on Sunday
evening or
Monday morning. Request parent/guardian/Relative Caregiver to provide spare
battery.
Evaluation of a hearing aid:
1. First look: Is student wearing the hearing aid or carrying it? Carrying it may mean
the student
does not wear the hearing aid and/or there is a problem with it.
2. Next check:
a. Can the student hear you?
b. Is it turned on? Is the volume control at an effective level?
3. Closer examination: May need to ask student to remove the hearing aid
a. Examine student’s ear: Assess for irritated spots (red or raw) which may indicate
the earmold
needs recasting or excessive cerumen. The presence of either requires medical
attention.
b. Examine hearing aid: Is it clean, especially the canal portion
c. Determine function: Create feedback by putting hand over the hearing aid and
listen for a
high pitched sound.
4. Tips for evaluating the hearing aid and troubleshooting equipment problems are
outlined in tables
on the following pages.
Care of the hearing aid:
1. Dirty earmold: Refer to parent/guardian/Relative Caregiver for cleaning or follow
the
manufacturer’s instructions. (Note: In most instances, the earmold can be detached,
washed in
lukewarm water, rinsed and dried thoroughly by blowing out the bubbles or
swabbing with a
pipe cleaner. However, some earmolds should not be washed in water.)

Section C - 93 - 02-2006

2. Battery compartment: If the hearing aid is not operating, check for proper battery
insertion.
Check to assure the “+”is placed next to the “+” on the battery compartment. If
battery
compartment is corroded, gently wipe with swab lightly dampened with rubbing
alcohol to
clean compartment and contacts.
Reinsertion
Have student reinsert hearing aid and make sure all switches are on to determine if
it is functioning.
Insert the earmold by pulling pinna back to enlarge the ear canal. With the mold
twisted slightly to
250

the rear of its “seating” position, insert in canal and twist forward to release pinna.
Referral:
If any problems are detected, notify parent/guardian/Relative Caregiver promptly in
order to address
the situation.
Role of the School Nurse
The school nurse provides a valuable support to students with hearing impairment.
Without periodic
monitoring, maintenance and compliance, the hearing aid can become ineffective
and compromise the
child’s academic success and well-being.
Resources
American Speech-Language-Hearing Association website at
http://www.asha.org/default.htm.
Delaware Division of Public Health,
http://www.dhss.delaware.gov/dhss/dph/dpc/diabetes/html.
References
Galludet University (n.d.). Support services handout series number 5003 audiology
sheet: Hearing
aids and other listening devices. Retrieved July 11, 2005 from
http://clercenter.galludet.edu/SupportServices/series/5003.html
Galludet University (n.d.). Support services handout series number 5004 audiology
sheet: How to
check a hearing aid. Retrieved July 11, 2005 from
http://clercenter.galludet.edu/SupportServices/series/5004.html

Section C - 94 - 02-2006

Evaluating Hearing Aid
Behind the Ear Aid In the Ear Aid Body Aid
_ Switch in "M" or mike position.
(Most ear level aids have
automatic internal switch).
_ Tone control at setting most
frequently used. (Most ear level
aids are set internally at time of
fitting.)
_ Does aid fit comfortably behind
ear or is tubing kinked or so
short that aid is pulled from
behind ear?
_ Cup hand over ear wearing aid.
Does it emit a steady squeal
(feedback)? This usually means
battery is supplying power and
amplified sound is reaching ear.
_ Check for cracked or aged
tubing/mold or loose fit of mold
to connector. Recommend
replacement.
_ Remove plastic tubing and
earmold from nozzle of the
hearing aid. Place thumb firmly
over nozzle opening. Slowly

251

turn volume control to
maximum. If feedback results
aid needs service.
_ Reattach tubing and earmold to
nozzle. Place thumb firmly over
earmold canal opening. Turn
volume control to maximum. If
feedback results aid needs
service.
_ Most are "on" when the battery
is inserted.
_ Tone control at setting most
frequently used. (Most ITE's are
set internally.)
_ Does aid fit comfortably?
_ Cup hand over ear wearing aid.
Does it emit a steady squeal
(feedback)? Supplying power
and amplified sound is reaching
the ear.
_ Check for cracked shell or loose
fit. Recommend replacing.
_ Place thumb firmly over ear
canal opening. Turn volume
control to maximum. If
feedback occurs, aid needs
service.
_ On/Off switch in "On"
position. Volume control
advanced to comfortable level.

Switch in "M" or mike
position.
_ Have control set at tone where
greatest amount of
amplification is needed.
_ Is aid secure in a harness or
clothing pocket?
_ Is cord excessively long, or so
short that it displaces ear mold.
Does it emit a steady squeal or
restricts freedom of
movement?
_ To check battery, bring
receiver close to main part of
aid. Feedback should occur.
_ Check cord for insulation
cracks, knots or severe
kinking. Unravel and
recommend replacing.
_ Mold should fit snugly on
receiver as well as cords into
sockets. If not recommend
remediation.
_ Place receiver to your ear.
Cover receiver with palm of

252

your hand and hold main part
at a distance to prevent
feedback; then…turn volume
control up and down, listening
for scratchiness or dead spots.
Control should neither be
excessively loose, nor bind
against case. Turn on/off
switch back and forth to check
for intermittent sound or loose
contacts. Change to other tone
positions H-M-L and listen for
appropriate pitch or quality
changes.
_ Roll cord back and forth
between fingers to check for
“cut-outs.”

Section C - 95 - 02-2006

Basic Guidelines for Troubleshooting
In the Ear Aid
Problem Possible Causes Remedy
1. Feedback
• Aid improperly inserted
• Dirty, plugged canal on aid
• Poor fit
• Remove and reset.
• Gently unplug with pipe cleaner.
Wipe clean.
• May need to be refitted with a new
aid
2. Intermittent
• Moisture in aid
• Weak battery
• Needs time to dry out (silica gel)
• Replace battery
3. Dead
• Dead battery
• Battery inserted backwards
• Switch in "off" position
• Replace
• Insert correctly
• Turn on

Behind the Ear Aid

Problem Possible Causes Remedy
1. Feedback
• Earmold improperly inserted
• Dirty, plugged earmold
• Poor fit earmold
• Cracked earmold
• Collapsed or kinked tubing or
coupler not tightened
• Remove and reset.
• Detach from hock nozzle and
wash with warm soapy water.
Blow or pipe clean water out of
canal.
• May need new earmold

253

• May need new earmold
• Eliminate kink; gently tighten
hook
2. Intermittent • Weak battery
• Moisture in aid
• Replace battery
• Silica gel
3. Dead
• Dead battery
• Battery inserted backwards
• Switch in "off" position
• Switch on Tel-coil
• Replace
• Insert correctly
• Turn on
• Switch to normal

Body or Conventional Aid
Problem Possible Causes Remedy
1. Feedback
(Squealing)
• Earmold improperly inserted
• Dirty, plugged earmold
• Poorly fitting earmold
• Remove and reset.
• Detach from cord, wash in warm,
mild soapy water. Blow or pipe
clean water out of canal.
• Needs new earmold. Alert
parent/guardian/Relative
Caregiver to check with
audiologist.
2. Intermittent
• Dirty cord contacts
• Dirty battery contacts
• Faulty cord – common reason
• Weak battery
• Disconnect; wipe contacts with
alcohol or brush lightly with
emery board.
• Remove battery; do above on
contacts.
• Aid on, run cord between fingers.
If intermittency duplicated,
replace cord.
• Replace.
3. Dead
• Dead battery
• Battery inserted backwards
• Switch in "off" position
• Switch on Tel-coil
• Replace
• Insert correctly
• Turn on
• Switch to normal

Section C - 96 - 02-2006

Oxygen Administration
Description
Oxygen is a licensed drug under FDA standards, complete with indications,
contraindications, dosage
254

ranges and potential for toxicity. As a drug, its dosage and administration must be
directed by the
prescription of a licensed healthcare provider.
Symptoms
The decision of how much oxygen to administer to a patient is based on several
factors. The first
considerations are the directives within the healthcare provider’s standing order.
When the order is
PRN, the following should be considered:
• Respiratory rate, pulse rate and blood pressure
• Level of consciousness
• Skin color and condition
• Oxygen saturation (pulse Oximetry)
• Presenting complaint/history of the chief complaint
• Pre-existing condition (asthma, cardiac, etc.)
• Age and size of patient
Nursing Assessment and Intervention
Routine Procedures Maintenance
Safe usage requires following the healthcare provider’s directions and the
manufacturers’
recommendations, instructions or operating manual. Individuals who assume the
responsibility for
oxygen equipment and its use must be familiar with the hazards of oxygen, the
operational
characteristics of the equipment, and the precautions to be observed while using
oxygen. Some areas
to be aware of include:
a. If using a disposable cylinder, do not refill under any circumstances.
b. Oxygen cylinders in use must be secured in an upright position.
c. All oxygen cylinders not in use must be stored in a well ventilated area and safe
from
environmental hazards, tampering, or the chance of accidental damage to the stem.
If stored
upright, the cylinders need to be secured. If stored horizontally, the cylinders must
be on a level
surface where they will remain stationary.
d. The content indicator should be checked at least monthly to determine amount of
oxygen in the
cylinder. This should be documented.
e. Common hazards associated with oxygen are ignition or heating sources. Friction
toys can create
sparks that can ignite oxygen. Cylinders must be kept away from these hazards.
f. Oxygen cylinders are required to have an expiration date. Equipment will need to
be recertified
periodically.
Emergency Equipment/Procedures
a. Have a standing order or PRN for emergency oxygen.
b. Select appropriate size mask or cannula.
c. Check tubing and cannula to be sure it is not twisted or kinked.

255

d. Attach cannula and tubing to oxygen source securely. (Some units also have
humidification
attachments.)
e. Set flow, if possible, to ordered rate.
f. Check for oxygen coming out of source.

Section C -97- 02-2006

g. Apply cannula or face mask to patient. When using nasal cannula, instruct patient
to breath
through the nose.
h. Monitor patient’s respiratory status.
i. Report signs and symptoms to medical personnel.
j. Document incident in student/staff file.
Role of the School Nurse
The need for oxygen administration may be a frightening time for the patient. The
placement of a
mask or nasal cannula may add additional fear to a patient who is already
experiencing breathing
difficulties. Clearly the role of the school nurse during oxygen administration is
providing
continuous medical assessment of vital signs and physical assessment of
respiratory status while
reassuring the patient.
References
Guide for the Safe Storage, Handling and Use of Liquid Oxygen in Health Care
Facilities, 2nd Edition,
(2000). Compressed Gas Association (CGA), Pamphlet CGQ p 2-7.
AARC Clinical Practice Guideline: Selection of an Oxygen Delivery Device for
Neonatal and
Pediatric Patients. (2002). Respiratory Care. 47(6), 707-716.
Guidance for Industry, May 2003. Retrieved at FDA:gov/cder/guidance/3823dft.pdf
on 7/21/05.

Section C -98- 02-2006

Seizure Management
Description
Epilepsy is a chronic, neurological condition that is characterized by the repeated,
unprovoked
occurrence of seizure activity. It is the main cause of seizure activity in the schoolaged student.
Approximately 2.3 million individuals are affected by epilepsy. Annually 181,000
Americans
develop epilepsy each year.
An Emergency Plan should be on hand for any student with known seizures.
Physician’s orders
related to procedure should be in place.
Etiology
Seizures occur from malfunctions of the brain’s electrical systems. Conditions
resulting in a single
seizure or epilepsy include such things as genetic/congenital disorders, trauma,
fever, infection,
electrolyte imbalance or hormonal changes.
256

Symptoms
Seizure Classification
A. Absence Seizure – brief lapses of consciousness (1-4 seconds) that look like
daydreaming, but
begin and end abruptly.
1. Partial Seizure – either type may evolve into a generalized tonic-clonic seizure.
2. Simple Partial – activity begins in and is usually limited to one part of either the
right or left
cerebral hemisphere and occurs without loss of consciousness; can present as
limited motor
activity, emotions, feelings, or sensations
B. Complex Partial – seizure occurs with impairment in the level of consciousness.
Produce
automatic movements and a period of confusion. Movements may look purposeful,
but are not.
C. Generalized Tonic-Clonic Seizure – affects the whole brain and body. There is loss
of
consciousness with stiffening and jerking. May fall. May have loss of bladder and/or
bowel.
Lasts an average of 1-2 minutes.
Preventative Measures
Triggering factors may be identified through careful and detailed documentation
that highlights a
pattern. Avoidance of triggers can reduce the incidence of the seizure. The goal in
epilepsy
management is to reduce the frequency and severity of seizures. Treatment
includes drug therapy,
surgical intervention, vagus nerve stimulatus and ketogenic diet.
Nursing Assessment and Intervention
A. Emergency Nursing Interventions for Generalized Tonic-Clonic Seizure
1. Lower the student to the floor and remove any objects in the area to prevent
injury. Leave the
student where he/she was when the seizure began as long as there is no
environmental
danger.
2. Turn the student to the side to prevent aspiration.
3. Loosen tight clothing.
4. Stay with the student and do not try to restrain movements, but protect the head.
5. Never put anything into the student’s mouth.

Section C -99- 02-2006

6. Monitor breathing. If the seizure is an extended one** (over 5 minutes), follow
physician’s
orders (which may include medication and oxygen administration) or call the
emergency
medical transport (911).
** Status Epilepticus – is a series of acute, prolonged and repetitive seizures without
a return
to consciousness between attacks. It is considered a serious neurological
emergency

257

necessitating airway management with oxygen and transport to a local medical
facility via
911.
7. Document observations and interventions (see Seizure Report on following page).
8. The postictal state can last minutes to hours. During this time the child should be
closely
supervised. Sleepiness, drowsiness, confusion and headache are common.
9. A seizure should be considered an emergency if:
• First time seizure
• Convulsive seizure lasting more than 5 minutes
• Repeated seizures without regaining consciousness
• More seizures than usual or change in type
• Student has diabetes or is pregnant
• Seizure occurs in water
• Student is injured
• Parent/Guardian/Relative Caregiver requests emergency evaluation
Transport the student immediately via ambulance to the nearest emergency facility.
B. Nursing Interventions for Complex Partial Seizure
1. Assess to determine if student has altered consciousness.
2. Until full awareness returns, guide student away from hazards but avoid hands-on
intervention.
Role of the School Nurse
A. Recognize seizure activity and its impact on students
B. Insure appropriate seizure first aid is given while minimizing stigma
C. Coordinate ongoing treatment with the student, parent/guardian/Relative
Caregiver, the school,
the healthcare team
D. Train teachers and other personnel to recognize and manage seizures and
minimize stigma
E. Help to create an environment in which the child continues to achieve
educational goals
Resources
Epilepsy Foundation of Delaware: www.efa.org
References
Managing Students with Seizures, Epilepsy Foundation of America and NASN, 2004
Jackson, P.L. & Vessey, J.A., Primary Care of the Child with a Chronic Condition, 3 rd
Edition, 2000.
www.cdc.gov/epilepsy
Wong’s Nursing Care of Infants & Children, 7 th Ed., Mosby, 2003
7/2005 Reviewed by Barbara H. Blair, RN, Executive Director, Epilepsy Foundation of
Delaware.

Section C -100- 02-2006

Seizure Action Plan

Please complete all questions. This information is essential for the school nurse and
school staff in
determining your student’s special needs and providing a positive and supportive
learning
environment. If you have any questions about how to complete this form, please
contact your child’s
school nurse.
258

Effective Date
Student’s Name: Date of Birth: Classroom:
Parent/Guardian/Relative Caregiver: Phone: Cell:
Treating Physician: Phone:
Medical History:
Seizure Information:
1. When was your child diagnosed with seizures or epilepsy?
2. Seizure type(s):
Seizure Type Average length Description

3. What might trigger a seizure in your child?
4. Are there any warnings, triggers and/or behavior changes before the seizure
occurs? YES NO
If YES, please explain:
5. How often does your child have a seizure?
6. When was your child’s last seizure?
7. Has there been any recent change in your child’s seizure patterns? YES NO
If YES, please explain:
8. How does your child react after a seizure is over?
How long does this usually last?
9. How do other illnesses affect your child’s seizure control?
Seizure Medication and Treatment Information:
10. What medication(s) does your child take?
Medication Date Started Dosage Frequency and time of day taken Possible side effects

1.
2.
3.

Section C -101 - 02-2006

Student’s Name
Emergency Response:
A “seizure emergency” for this student is defined as:
11. What emergency/rescue medications are prescribed for your child?
Name Dosage Administration instructions
(timing* & method**)
What to do after
administration:
1.
2.
* After 2nd or 3rd seizure, for cluster of seizure, etc. ** Orally, under tongue, rectally, etc.

Seizure Emergency Protocol: (Check all that apply and clarify below)
_ Contact school nurse at
_ Call 911 for transport to
_ Notify parent or emergency contact
Telephone number
_ Notify doctor
Telephone number
_ Administer emergency medications as indicated
_ Other
Does student have a Vagus Nerve Stimulator (VNS)? YES NO
If YES, describe magnet use
Special Considerations & Safety Precautions:
(regarding school activities, sports, trips, etc.)
259

Physician Signature: Date:
Parent Signature: Date:
This form combines two forms (one for parents and one for physician) created by the Epilepsy Foundation and the
National Association of
School Nurses in 2004.
A Seizure is generally considered an
Emergency when:
• A convulsive (tonic-clonic) seizure
lasts longer than 5 minutes
• Student has repeated seizures
without regaining consciousness
• Student has a first time seizure
• Student is injured, has diabetes, or is
pregnant
• Student has breathing difficulties

Section C -102- 02-2006
SEIZURE REPORT

STUDENT
AURA: Yes No If yes, Type: _ auditory _ tactile
_ olfactory _ visual
Date: Time:
DID STUDENT MAKE ANY NOISES? Yes No
DURATION (length of time):
DESCRIPTION OF MOVEMENT & BEHAVIORS (stiffness, shaking, repetitive behaviors,
other)
LOSS OF CONSCIOUSNESS: Yes No If yes, how long:
ONSET: Face: Rt. Arm: Rt. Leg: Left Arm: Left Leg:
Spreading: Generalized at Onset:
Turning of Eyes: Turning of Body: Direction:
POSTICTAL STATE: A) Sleepiness Yes No
B) Drowsiness Yes No
C) Confusion Yes No
D) Psychotic Behavior Yes No
If answer to D) is Yes, Describe:
DESCRIBE INJURIES, IF ANY:
INCONTINENCE: Bowel - Yes No
Bladder - Yes No
EXCESSIVE SALIVATION: Yes No
CYANOSIS: Yes No
COMMENTS:
Witnessed by:
Signature Title
Contacted: _ Parent/Guardian/Relative Caregiver Date: Time:
_ Licensed healthcare provider Date: Time:
_ Other Date: Time:

Section C -103- 02-2006

INDIVIDUALIZED HEALTHCARE PLANS
An Individualized Healthcare Plan (IHP) is an efficient vehicle for planning and
evaluating care of
students with complex health conditions or those needing modifications of the
school environment.
The IHP is similar to traditional nursing care plans, but individualized to the specific
student and
260

school setting. While standardized IHPs for commonly occurring conditions in
students are available,
each must be modified and customized for each student. There are commonalities
amongst IHPs.
The Delaware template on the following page incorporates those.
Standardized Language1
Standardized language within school nursing facilitates accurate communication,
research and
ultimately quality care of students. Through the use of common terminology or
nomenclature, school
nurses can communicate about student symptomatology, nursing care and goals.
Standardized
language is particularly helpful when preparing an IHP.
Nursing Diagnosis
Nursing diagnosis is the nurse’s judgment or decision, relative to the client’s health
needs.
“Nursing diagnosis is the recommended method of written communication for
nursing. School
nursing is a specialty within the nursing profession. School health nurses should
understand and
utilize nursing diagnosis to meet the needs of their clients. The NASN supports the
use of NANDA
diagnosis in the school health setting.” (NASN. [2000]. Position Statement on
Nursing Diagnosis.
Scarborough, Maine. www.nasn.org)
Nursing Intervention Classification (NIC)
NIC is a unique vocabulary that describes actions performed by a nurse.
Interventions can be
independent or collaborative, direct or indirect, and individual or group oriented. NIC
was initially
created for hospital use, but use within the specialty practice of school nursing is
growing.
Nursing Outcome Classification (NOC)
NOC succinctly describes the desired or attained outcome that results from planned
nursing
interventions and patient goals. It helps the nurse and patient to measure and
assess goals.
Resources:
Haas, Mary Kay B. The School Nurse’s Source Book of Individualized Healthcare
Plans, Volumes 1
and 2. North Branch, MN: Sunrise River Press.
Hootman, Janice. Quality Nursing Interventions in the School Setting: Procedures,
Models, and
Guidelines, 2nd Edition. NASN, ME, 2004.
NASN Position Statement. Case Management of Children with Special Healthcare
Needs.
http://www.nasn.org/positions/2002pscase.pdf
NASN Position Statement, Individualized Health Care Plans.
http://www.nasn.org/positions/2003psindividualized.pdf

261

The NASN’ Position Statement, Nursing Classification Systems: NANDA, NIC & NOC,
provides an
overview. It can be accessed at http://www.nasn.org/positions/2001psnursing.htm.
1

Section C -104- 02-2006

Individualized Healthcare Plan
Name: Birthdate: Grade:
Healthcare Provider: Provider’s Phone:
IHP Written by: , RN
IHP Date: Review Date:
Student Goals: 1.
2.
Health History [including current medication(s), current treatment(s) and/or
baseline data] relative to IHP:
Nursing Diagnosis
NANDA
Nursing Interventions
NIC
Student Outcomes
NOC
Section D - 1 - 9-2008

Section D.
School Programs and Resources
I. The Delaware Education Support System (DESS)
II. Connections to Learning
A. Overview
B. The Role of the School Nurse
III. Connections to Learning Subdomains
A. Health, Nutrition and Physical Activity
1. Dental Health
2. Driver Education
3. Health Education
4. Nutrition
5. Physical Activity
B. School Climate
1. School Crisis Plans/ Emergency Preparedness
2. Staff Wellness/ Back Protection
3. Recommended Space and Supplies/Equipment in the School Nurses’
Office
C. Social and Emotional Health
1. Caregiver’s Law
2. Child Abuse and Neglect
3. Domestic Violence
4. Homeless Students
5. Mental Health
6. Safe Arms for Babies
262

7. School Health Counseling
8. Substance Abuse
The information in Section D presents school programs and resources that address the safety
and well
being of all students. The material is presented in a framework consistent with the Delaware
Department of Education’s approach to student success and incorporates the processes of the
Delaware Education Support System (DESS). The role of the school nurse is critical in
supporting the
holistic needs of a child and will vary from one school to another. As the health resource within
the
school facility, it is important for the school nurse to be knowledgeable of ongoing programs and
community resources.
Section D - 2 - 9-2008

I. The Delaware Education Support System
(DESS)
Section D - 3 - 9-2008

I. Delaware Education Support System (DESS)
The Delaware Education Support System (DESS) is the process whereby the Delaware Department of
Education (DDOE) supports continuous improvement of Delaware public education. DESS is one way
DDOE
fulfills its mission

“To promote the highest quality education for every Delaware student by providing
visionary
leadership and superior service.”
DESS provides a framework for building district capacity to address Leadership for Learning, Teaching
and
Learning, and Connections to Learning through a wide range of services to Delaware public school
districts,
schools, early childhood programs, and interagency collaborative projects. The individual student (birth to
age
21) is at the center of each domain of the DESS model.
Leadership for Learning strengthens administrative leaders within districts and schools. Teaching and
Learning addresses curriculum and teaching strategies. Connections to Learning brings together
support
systems and those areas that influence the child’s overall social, emotional and physical well-being. By
increasing communication and focusing on “connecting” areas that support student learning, school teams
will
work more efficiently to improve student success. Health Services is a part of Connections to Learning.
Connections to Learning is a strategy to support student learning by supporting the “whole child”.
Within this
domain are three interconnected subdomains that identify critical areas of focus that impact student
learning:
1. Health, Nutrition, and Physical Activity
2. School Climate
3. Social and Emotional Health
Connections
to

263

Learning
Teaching
and
Learning
Leadership
for
Learning

Section D - 4 - 9-2008

II. Connections to Learning
Section D - 5 - 9-2008

II. Connections to Learning
A. Overview
Student success has always been the central goal of education; however, programming related to
the
holistic health of the student has historically been fragmented in silos and not based on the
statistical
needs of the student. The vision of Connections is to “connect” disciplines at DDOE and in
districts.
DDOE has developed a coordinated, holistic approach to address barriers to learning and
promote
health and social development through a process called “Connections to Learning”. This
comprehensive collaboration and integrative approach to improve student health and academic
outcomes is based in part on the Centers for Disease Control (CDC) Coordinated School Health
Program (CSHP) model, the Positive Behavior Support (PBS) model, and best practices in early
childhood education. To be prepared for the 21st Century, the Association for Supervision and
Curriculum Development (ASCD) has proposed that schools ensure that each child is healthy,
safe,
engaged, supported and challenged. In order to make the greatest impact, the social, emotional
environmental, behavioral and physical needs of the whole child should be addressed in a
collaborative
and coordinated way.
An essential component to the Connections process is the collection and analysis of data that
identifies
student needs regarding school climate, health risk behavior, student fitness, and family
involvement
and other factors so schools and districts can accurately identify and prioritize needs to improve
student outcomes.
The subdomains of Connections are embedded with the core concepts of diversity, character
development and family and community collaboration. Each is essential in the shaping of
teams,
data analysis and strategic planning.
Section D - 6 - 9-2008

CONNECTIONS TO LEARNING
Character Development Family & Community
Collaboration
Diversity

264

Most nurses are familiar with a Coordinated School Health Program (CSHP), which is a
multidimensional
program that increases the probability of having a healthy student who is ready to learn
and one who will learn to his/her potential. There are many similarities between Connections to
Learning and a CSHP Program model. It is a school-based program with a broad spectrum of
activities
and services which take place in schools and the surrounding communities to enable all members
of
the school community to enhance their physical, mental and social well-being. For many years
the
literature referred to a school health program as being comprised of three components - health
education, health services, and a healthy school environment. The CDC model, which appeared
around
1990, created a broader context of the school health program to include the physical education
program, counseling and psychological services, food service programs, health promotion for the
faculty and staff, and integrated efforts of the school, community, and parents to address the
health of
students. The rationale for an expanded model was simple - by coordinating the efforts and
resources
of programs designed to improve the health of students and staff, the result could produce greater
effectiveness than if delivered in isolation.
Schools with any sort of student support teams already in place (CSHP, Positive Behavior
Support,
Student Assistance, Wellness Policy, etc.) will find the Connections to Learning philosophy
parallels
their foundational concepts. Building on an existing team, additional members will need to be
added to
ensure every subdomain is represented.
The Connections to Learning book, which provides more details is available at the following
link:
http://www.doe.k12.de.us/programs/DESS/connections_to_learning.shtml
School
Climate
Social & Emotional
Health
Health, Physical
Activity & Nutrition

Section D - 7 - 9-2008

B. The Role of the School Nurse
School Nurses and School Health Services relate directly to the Connections to Learning process.
The
success of the School Health program is closely linked to the ability of the school nurse to
successfully
develop and implement programs that address the needs of the school community. The school
nurse
cares for clients meeting emergency and chronic health needs, in addition to providing
preventative

265

services and screening for potential health problems. School nurses advocate for, plan, and
implement
diverse programs to meet identified needs. The rising numbers of chronic illness among children
has
initiated new programs and strategies for school nurses to use with students, schools, and
families.
Working with community partners and national programs, school nurses provide health
education and
“connect” families with necessary resources.
School Nurses are known experts in the area of school health, making them key players in the
integration of Connections to Learning. Possessing excellent collaboration skills, school nurses
can
easily facilitate the development of meaningful partnerships among school staff, families and
communities to maximize student health and well-being. Together they can help students gain
the
knowledge, skills and awareness of resources to help them grow up to be healthy and productive
adults. The dual roles and the many responsibilities that school nurses possess make their
practice
instrumental in promoting a positive school climate, increasing academic achievement,
enhancing
lifelong wellness among students, families, educators, and communities. As a Connections team
member, the school nurse contributes by sharing health information (statistics, trends, etc.),
analyzing
health data in conjunction with other data sets, and contributing to school and student success
planning.
Resources:
Centers for Disease Control (CDC) Healthy Youth: http://www.cdc.gov/HealthyYouth/index.htm
National Association of School Nurses: www.nasn.org
U.S. Department of Health and Human Services: www.healthypeople.gov
Section D - 8 - 9-2008

III. Connections to Learning Subdomains:
A. Health, Nutrition and Physical Activity
B. School Climate
C. Social and Emotional Health
Section D - 9 - 9-2008

III. Connections to Learning Subdomains
A. Health, Nutrition and Physical Activity
1. Dental Health
Dental Health Program
It is estimated that 90% of the students of school age suffer from dental caries or other dental
problems. It is important that each student receive an oral examination and evaluation each year
by a
dentist. Some schools employ dental hygienists, but in most instances, the school nurse
participates in
266

the dental health program and makes appropriate referrals. In 2006 a Sealant Program was
initiated for
all second graders to meet underserved areas.
Objectives:
• To assist the student in assuming responsibility for his/her dental hygiene.
• To include dental health activities with the total school health program.
Activities:
• Emphasize early and regular periodic examination.
• Assist families in accessing local dental services.
• Contact the state service center for referrals to the dental clinic (current list of Medicaid
dentist list is provided on the following pages).
• Participate in health education regarding dental hygiene.
• Encourage appropriate nutritional choices.
• Encourage the use of mouthguards in contact sports to prevent injury and loss of teeth.
• Discourage the use of all tobacco products.
Contact the Delaware State Dental Society (www.delawarestatedentalsociety.org) for more
information.
Section D - 10 - 9-2008

DENTISTS ENROLLED IN DELAWARE’S MEDICAID PROGRAM As of June 29, 2008
LAST NAME
FIRST
NAME SPECIALTY CTY ADDRESS ADDRESS 2 CITY ST ZIP
PHONE
NUMBER
SERVICE
AREA REMARKS
Alban Steven General/Family/Pediatric K 550 S. DUPONT HWY SUITE A Milford DE 19963 302-422-9637 Milford
Aloe Michael Endodontist K 850 SOUTH STATE STREET Dover DE 19901 302-736-6631 Dover
Annone Anne General/Family/Pediatric N 600 NORTH BROAD STREET SUITE 7 Middletown DE 19709 302-832-1371 Newark
Anzilotti Kert General/Family/Pediatric N 1415 FOULK ROAD SUITE 200 Wilmington DE 19803 302-477-4900 Wilmington
Anzilotti, Jr. Clifford Orthodontist N 2101 FOULK RD Wilmington DE 19810 302-475-2050 Wilmington
Anzilotti, Sr. Clifford Orthodontist N 2101 FOULK RD Wilmington DE 19810 302-475-2050 Wilmington
Arrighi Scott General/Family/Pediatric N 102 SLEEPY HOLLOW
DRIVE
SUITE 100 Middletown DE 19709 302-376-9159 Middletown/
Odessa
Ashrafi Zahra General/Family/Pediatric N 129 S. WEST STREET Wilmington DE 19801 302-230-0000 Wilmington
Awayes Adly General/Family/Pediatric K 513 SOUTH DUPONT
HIGHWAY
Milford DE 19963 302-422-7800 Milford
Bailey Mary Ann General/Family/Pediatric K 26 WYOMING AVENUE DELMARVA
RURAL MNISTRIES
Dover DE 19904 302-678-2000 Dover
Baran Christopher General/Family/Pediatric N 3105 LIMESTONE ROAD SUITE 305 Wilmington DE 19808 302-995-7128 Wilmington
Barnhart Ryan General/Family/Pediatric S 34359 CARPENTERS WAY Lewes DE 19958 302-645-8993 Lewes
Barrett Lawrence Oral Surgeon MD 314 FRANKLIN AVE #401 Berlin MD 21811 410-641-4710 Berlin, MD
Bernick Sheldon General/Family/Pediatric PA 1999 SPROUL ROAD SUITE 14 Broomall PA 19008 610-356-1454 Broomall,
PA
Binnersley Ian General/Family/Pediatric N 1415 FOULK ROAD SUITE 201 Wilmington DE 19803 302-378-8600 Middletown/
Odessa
Bishop Taurance General/Family/Pediatric N 300 BIDDLE AVENUE CONNOR BLDG STE
204
Newark DE 19702 302-838-8306 Newark
Block David General/Family/Pediatric N 106 ST ANNES CHURCH RD Middletown DE 19709 302-378-8600 Middletown/
Odessa
Bond Donald General/Family/Pediatric N 12 POLLY DRUMMOND
HILL ROAD
Newark DE 19711 302-731-4225 Newark
Bond Richard General/Family/Pediatric N 1415 FOULK ROAD SUITE 200 Wilmington DE 19803 302-477-4900 Wilmington
Bradley Erik General/Family/Pediatric N 1415 FOULK ROAD SUITE 200 Wilmington DE 19803 302-477-4900 Wilmington

267

Section D - 11 - 9-2008
Brafman Kevin General/Family/Pediatric S 31381 DOGWOOD ACRES
RD
UNIT 2 Dagsboro DE 19939 302-732-3852 Dagsboro
Brafman Wendy General/Family/Pediatric S 31381 DOGWOOD ACRES
RD
UNIT 2 Dagsboro DE 19939 302-732-3852 Dagsboro
Bragan Georgette General/Family/Pediatric N 625 BARKSDALE RD SUITE 115-117 Newark DE 19711 302-731-4907 Newark
Brenner Charles Pedodontist MD 145 EAST CARROLL
STREET
SUITE 201 Salisbury MD 21801 410-749-0133 Salisbury,
MD
Bresler David General/Family/Pediatric PA 6801 RIDGE AVENUE Philadelphia PA 19128 215-483-6633 Philadelphia,
PA
Bright Jeffrey General/Family/Pediatric N 600 NORTH BROAD STREET SUITE 7 Middletown DE 19709 302-376-7882 Middletown/
Odessa
Broder Michelle General/Family/Pediatric N 2300 PENNSYLVANIA AVE SUITE 5C Wilmington DE 19806 302-652-1533 Wilmington
Broomall Pediatric Dentistry
and Orthodontics PC
General/Family/Pediatric PA 1999 SPROUL ROAD SUITE 14 Broomall PA 19008 610-356-1454 Broomall,
PA
Bunting Lucinda General/Family/Pediatric K 615 N DUPONT Milford DE 19963 302-424-7976 Milford
Burke John General/Family/Pediatric N 3105 LIMESTONE ROAD SUITE 305 Wilmington DE 19808 302-995-7128 Wilmington
Burns Christopher Prosthodontics K 871 SOUTH GOVERNORS
AVENUE
SUITE #1 Dover DE 19904 302-674-8331 Dover
Cahoon Michael Oral Surgeon S KINGSWAY
PROFESSIONAL BLDG
750 KINGS
HIGHWAY STE 107
Lewes DE 19958 302-644-4171 Lewes
Calhoon Charles General/Family/Pediatric N 17 POLLY DRUMMOND CTR
102
Newark DE 19711 302-731-0202 Newark
Capodanno John Oral Surgeon K 1001 S BRADFORD ST SUITE 2 Dover DE 19904 302-674-4450 Dover
Carr Suk Young Endodontist K 850 SOUTH STATE STREET Dover DE 19901 302-736-6631 Dover
Carroccia Richard General/Family/Pediatric N 1415 FOULK ROAD SUITE 200 Wilmington DE 19803 302-477-4900 Wilmington
Cha Moon General/Family/Pediatric N 344 E. MAIN STREET NEWARK DENTAL
ASSOCIATES
Newark DE 19711 302-737-5170 Newark
Chodroff Richard Periodontist N 3105 LIMESTONE ROAD SUITE 203 Wilmington DE 19808 302-995-6979 Wilmington
Chou Joseph General/Family/Pediatric N 344 E. MAIN STREET NEWARK DENTAL
ASSOCIATES
Newark DE 19711 302-737-5170 Newark
Christian Paul General/Family/Pediatric N 423 EAST MAIN STREET ASHLEY PLAZA Middletown DE 19709 302-376-9600 Middletown/
Odessa
Christiana Care
Department of Dentistry
General/Family/Pediatric N 501 WEST 14TH STREET PO BOX 1668 Wilmington DE 19899 302-428-4850 Wilmington
Christiana Care
Department of Dentistry
Specialist N 501 WEST 14TH STREET PO BOX 1668 Wilmington DE 19899 302-428-4850 Wilmington

Section D - 12 - 9-2008
Cicorelli Connie General/Family/Pediatric N 1401 SILVERSIDE ROAD SUITE 2A Wilmington DE 19810 302-798-5797 Wilmington
Clay Rosemary General/Family/Pediatric N 533 MAIN STREET Wilmington DE 19804 302-998-0500 Wilmington
Cole Jeffrey General/Family/Pediatric N 2396 LIMESTONE ROAD Wilmington DE 19808 302-633-2900 Wilmington
Collins Dale Pedodontist N 5500 SKYLINE DRIVE Wilmington DE 19808 302-239-3655 Hockessin
Collins Gary Orthodontist N 5500 SKYLINE DRIVE Wilmington DE 19808 302-239-3531 Wilmington
Collins Lynn Pedodontist N COLLINS DENTAL ASSOC 38 PEOPLES PLAZA Newark DE 19702 302-834-4000 Newark Sees children
up to age 14
Collins Lynn Orthodontist N COLLINS DENTAL ASSOC 38 PEOPLES PLAZA Newark DE 19702 302-834-4000 Newark Sees children
up to age 14
Collins Robert General/Family/Pediatric N 5500 SKYLINE DRIVE Wilmington DE 19808 302-239-3655 Hockessin
Collins Ron Pedodontist N COLLINS DENTAL ASSOC 38 PEOPLES PLAZA Newark DE 19702 302-834-4000 Newark Sees children
up to age 14
Collins Ron Orthodontist N COLLINS DENTAL ASSOC 38 PEOPLES PLAZA Newark DE 19702 302-834-4000 Newark Sees children
up to age 14
Conaty Thomas General/Family/Pediatric N 2003 BRANDYWOOD LANE Wilmington DE 19810 302-478-5269 Wilmington
Conley Thomas General/Family/Pediatric S 55 RT 24 Lewes DE 19971 302-645-6671 Lewes

268

Coope Robert General/Family/Pediatric K 863 BUTTNER PLACE STE 203 Dover DE 19904 302-741-2044 Dover
Cornatzer Joseph General/Family/Pediatric N 7197 LANCASTER PIKE Hockessin DE 19707 302-239-5917 Hockessin
D'Amico Eugene Oral Surgeon N B92 OMEGA DR Newark DE 19713 302-292-1600 Newark
Daniels V.J. General/Family/Pediatric N 2300 PENNSYLVANIA AVE SUITE 2C Wilmington DE 19806 302-655-8387 Wilmington
D'Antonio Richard General/Family/Pediatric N 1415 FOULK ROAD SUITE 201 Wilmington DE 19803 302-477-4900 Wilmington
D'Arro Carmelina General/Family/Pediatric N 601 NEW CASTLE AVENUE Wilmington DE 19801 302-655-6187 Wilmington
Deakyne David General/Family/Pediatric K 27 DEAK DRIVE Smyrna DE 19977 302-653-6661 Smyrna
Deakyne, Jr. David General/Family/Pediatric K 27 DEAK DRIVE Smyrna DE 19977 302-653-6661 Smyrna
Dearing Gregory Endodontist N 112 SAINT ANN'S CHURCH
RD
Middletown DE 19709 302-285-0350 Middletown/
Odessa
DeCouto Douglas General/Family/Pediatric N 1290 PEOPLES PLAZA Newark DE 19702 302-836-3750 Newark

Section D - 13 - 9-2008
Del Tech Dental Health Center General/Family/Pediatric N 333 N. SHIPLEY STREET Wilmington DE 19801 302-571-5364 Wilmington
Delmarva Rural Ministries General/Family/Pediatric K 26 WYOMING AVENUE Dover DE 19904 302-678-2000 Dover
Derenzo George Pedodontist N 2000 FOULK ROAD SUITE C Wilmington DE 19810 302-475-3110 Wilmington
Diecidue Robert Oral Surgeon PA 834 CHESTNUT STREET,
STE 311
C/O JUP CNTRL
ENROLLMENTS
Philadelphia PA 19107 215-955-9628 Philadelphia,
PA
Director Robert Endodontist N 1110 NORTH BANCROFT
PKWY
Wilmington DE 19805 302-658-7358 Wilmington
Ditty Douglas Oral Surgeon K 1001 S BRADFORD ST SUITE 2 Dover DE 19904 302-674-4450 Dover
Dougherty Thomas Oral Surgeon N 5317 LIMESTONE ROAD Wilmington DE 19808 302-239-2500 Hockessin
Dover Junior General/Family/Pediatric N 1290 PEOPLES PLAZA BEAR-GLASGOW
DENTAL
Newark DE 19702 302-836-3750 Newark
Dunhoft Korie General/Family/Pediatric N COLLINS DENTAL ASSOC 38 PEOPLES PLAZA Newark DE 19702 302-834-4000 Newark Sees
children
up to age 14
Ehrenfeld David General/Family/Pediatric N 710 GREENBANK ROAD Wilmington DE 19808 302-994-2582 Wilmington
Elkington Isaac Kent General/Family/Pediatric S 218 PENNSYLVANIA
AVENUE
Seaford DE 19973 302-629-3008 Seaford
Ettinger David Oral Surgeon N 850 LIBRARY AVE SUITE 102 Newark DE 19711 302-369-1000 Newark
Fagioletti Lisa General/Family/Pediatric N 850 LIBRARY AVE SUITE 102 Newark DE 19711 302-366-8668 Newark
Farhi Adeline General/Family/Pediatric N 301 SOUTH DUPONT ROAD ELSMERE DENTAL
ASSOCIATES
Wilmington DE 19804 302-998-9244 Wilmington
Farhi Parham General/Family/Pediatric N 301 SOUTH DUPONT ROAD ELSMERE DENTAL
ASSOCIATES
Wilmington DE 19804 302-998-9244 Wilmington
Fay Brendan General/Family/Pediatric N 1802 W 4TH ST Wilmington DE 19805 302-655-5822 Wilmington
Fay Bruce General/Family/Pediatric N 900 FOULK ROAD SUITE 203 Wilmington DE 19803 302-778-3822 Wilmington
Fidance Ernest General/Family/Pediatric N 1415 FOULK ROAD SUITE 201 Wilmington DE 19803 302-656-8219 Wilmington
Fink Daniel General/Family/Pediatric N 3600 SILVERSIDE RD STE A Wilmington DE 19810 302-479-7111 Wilmington
Fink Fred Orthodontist N 3518 SILVERSIDE ROAD 23 THE COMMONS Wilmington DE 19810 302-478-6930 Wilmington
Fink Gregg General/Family/Pediatric N ONE CENTURIAN DRIVE SUITE 213 Newark DE 19713 302-998-6300 Newark
Fisher Bruce Oral Surgeon K 33718 WESCOATS ROAD SUITE A Lewes DE 19958 302-644-2977 Lewes

Section D - 14 - 9-2008
Fiss Mark Orthodontist N 4901 LIMESTONE ROAD Wilmington DE 19808 302-239-4600 Wilmington
Fontana John General/Family/Pediatric N 1701 LOVERING AVENUE STE 101 Wilmington DE 19806 302-656-2434 Wilmington
Fortunato Mark General/Family/Pediatric N 1415 FOULK ROAD SUITE 201 Wilmington DE 19803 302-656-8219 Wilmington
Friz William General/Family/Pediatric N 1415 FOULK ROAD SUITE 200 Wilmington DE 19803 302-477-4900 Wilmington
Ganfield Timothy General/Family/Pediatric N 12 POLLY DRUMMOND
HILL ROAD
Newark DE 19711 302-731-4225 Newark
Ganjavian Syamack General/Family/Pediatric N 828 N. UNION ST. Wilmington DE 19805 302-777-4121 Wilmington
Gaz David John General/Family/Pediatric N 106 ST ANNES CHURCH RD Middletown DE 19709 302-378-8600 Middletown/
Odessa
Gerber Danielle General/Family/Pediatric N 1290 PEOPLES PLAZA BEAR-GLASGOW
DENTAL
Newark DE 19702 302-836-3750 Newark
Giles Howard General/Family/Pediatric N 1415 FOULK ROAD SUITE 200 Wilmington DE 19803 302-477-4900 Wilmington
Gioffre Dominic General/Family/Pediatric N 4901 LIMESTONE ROAD Wilmington DE 19808 302-239-0410 Hockessin

269

Gioffre, Jr. D. Michael General/Family/Pediatric N 1708 LOVERING AVENUE SUITE 102 Wilmington DE 19806 302-652-5312 Wilmington
Giordano Lawrence Oral Surgeon N 1601 MILLTOWN ROAD SUITE 17 Wilmington DE 19808 302-995-1870 Wilmington
Gladnick Dann General/Family/Pediatric N 1104 N BROOM STREET Wilmington DE 19806 302-654-7243 Wilmington
Gladnick Mark General/Family/Pediatric N 5513 KIRKWOOD HIGHWAY KIRKWOOD
MILLTOWN
PROFESSION
Wilmington DE 19808 302-994-2660 Wilmington
Goldfeder Allan General/Family/Pediatric N 2415 MILLTOWN ROAD Wilmington DE 19808 302-994-1782 Wilmington
Goleburn Glen General/Family/Pediatric N 1290 PEOPLES PLAZA BEAR-GLASGOW
DENTAL
Newark DE 19702 302-836-3750 Newark
Goleburn Stanley General/Family/Pediatric N 1290 PEOPLES PLAZA BEAR-GLASGOW
DENTAL
Newark DE 19702 302-836-3750 Newark
Gonce William General/Family/Pediatric N 530 SCHOOL HOUSE ROAD SUITE F Hockessin DE 19707 302-235-2400 Hockessin
Goodwill James Oral Surgeon N 1304 N BROOM STREET Wilmington DE 19806 302-998-0331/
655-6183
Wilmington
Grandison Dawn General/Family/Pediatric N 1290 PEOPLES PLAZA BEAR-GLASGOW
DENTAL
Newark DE 19702 302-836-3750 Newark
Granite Edwin Oral Surgeon N 2101 FOULK ROAD Wilmington DE 19810 302-475-1122 Wilmington
Gregory Victor General/Family/Pediatric N 5301 LIMESTONE ROAD SUITE 211 Wilmington DE 19808 302-239-1827 Hockessin

Section D - 15 - 9-2008
Hansen Greg General/Family/Pediatric N 1415 FOULK ROAD SUITE 201 Wilmington DE 19803 302-378-8600 Middletown/
Odessa
Harris Jay General/Family/Pediatric N 220 CHRISTIANA MED CTR Newark DE 19702 302-453-1400 Newark
Hazuda Michael General/Family/Pediatric N 5301 LIMESTONE RD STE
212
STONEY BATTER
OFFICE BLDG
Wilmington DE 19808 302-239-8230 Hockessin
Henrietta Johnson Medical
Center
General/Family/Pediatric N 601 NEW CASTLE AVENUE Wilmington DE 19801 302-655-6187 Wilmington
Herb Kathleen Oral Surgeon PA 834 CHESTNUT STREET,
STE 311
C/O JUP CNTRL
ENROLLMENTS
Philadelphia PA 19107 215-955-9628 Philadelphia,
PA
Holley James Periodontist VA 446 EFFINGHAM STREET Portsmouth VA 23704 757-393-2401 Portsmouth,
VA
Honig Gordon Orthodontist N 2707 KIRKWOOD HIGHWAY Newark DE 19711 302-737-6333 Newark
Hounsell Jill General/Family/Pediatric N 38 PEOPLES PLAZA Newark DE 19702 302-834-4000 Newark Sees children
up to age 14
Isaacs David General/Family/Pediatric N ISAACS & ISAACS FAMILY
DEN
707 FOULK ROAD Wilmington DE 19803 302-654-1328 Wilmington
Isaacs Milton General/Family/Pediatric N 707 FOULK ROAD Wilmington DE 19803 302-654-1328 Wilmington
Jacobs Laurie Pedodontist N 708 FOULK ROAD Wilmington DE 19803 302-764-7714 Wilmington
Jain Arvind General/Family/Pediatric MD 123 W COLLEGE AVE Salisbury MD 21804 410-546-5900 Salisbury,
MD
Jolly Jeena General/Family/Pediatric K 26 WYOMING AVENUE DELMARVA
RURAL MNISTRIES
Dover DE 19904 302-678-2000 Dover
Jones Blair General/Family/Pediatric S 34359 CARPENTERS WAY Lewes DE 19958 302-645-8993 Lewes
Jones Donald General/Family/Pediatric N 1 WINSTON AND
MARYLAND AVE
Wilmington DE 19804 302-656-8266 Wilmington
Kacmarcik Robert General/Family/Pediatric N 5301 LIMESTONE ROAD SUITE 122 Wilmington DE 19808 302-235-7645 Hockessin
Kelly, Jr. Joseph General/Family/Pediatric N 2205 SILVERSIDE RD SUITE 2 Wilmington DE 19810 302-475-5555 Wilmington
Kim Jung Endodontist N 1815 W 13TH STREET #7 Wilmington DE 19806 302-652-3556 Wilmington
King David Oral Surgeon N 1304 N BROOM STREET Wilmington DE 19806 302-998-0331/
655-6183
Wilmington
Kionke Cathy General/Family/Pediatric N JAMES V TIGANI III DMD 1021 GILPIN AVE
STE 205
Wilmington DE 19806 302-571-8740 Wilmington
Klassman Bradford Periodontist N 1110 NORTH BANCROFT

270

PKWY
Wilmington DE 19805 302-658-7871 Wilmington
Kremer Michael Oral Surgeon N 1304 N BROOM STREET 10 HERITAGE
PROF. PLAZA
Wilmington DE 19806 302-998-0331/
655-6183
Wilmington

Section D - 16 - 9-2008
Kreshtool Daniel Endodontist N 1815 W 13TH STREET #7 Wilmington DE 19806 302-652-3556 Wilmington
Kuon Thomas General/Family/Pediatric S 34539 CARPENTERS WAY Lewes DE 19958 302-645-8993 Lewes
Kwon Myochul General/Family/Pediatric N 1802 W 4TH ST Wilmington DE 19805 302-655-5822 Wilmington
Labin Charles General/Family/Pediatric S 34359 CARPENTERS WAY Lewes DE 19958 302-645-8993 Lewes
Lemper Jian Ying
Chen
General/Family/Pediatric PA 207 NORTH GUERNSEY
ROAD
West Grove PA 19390 610-869-0991 West Grove,
PA
Levin Lawrence Oral Surgeon PA 34th & CIVIC CENTER BLVD CHILDREN'S
SURGICAL
ASSOCIATES, LTD
Philadelphia PA 19104 215-590-8794 Philadelphia,
PA
Levine Alan General/Family/Pediatric N 2018 NAAMANS ROAD SUITE #2 Wilmington DE 19810 302-475-3743 Wilmington
Lippman Norman Oral Surgeon K 712 S GOVERNORS
AVENUE
Dover DE 19904 302-674-1140 Dover
Liu Grace General/Family/Pediatric N 1415 FOULK ROAD STE 201 Wilmington DE 19803 302-477-4900 Wilmington
Lynch John General/Family/Pediatric S 543 SHIPLEY ST SUITE E Seaford DE 19973 302-629-7115 Seaford
Maguire Charles General/Family/Pediatric N 1401 PENNSYLVANIA
AVENUE
UNIT 106 Wilmington DE 19806 302-654-0566 Wilmington
Maher Rachel Pedodontist N 2036 FOULK RD SUITE 200 Wilmington DE 19810 302-475-7640 Wilmington
Marsico Franklin General/Family/Pediatric N 625 BARKSDALE ROAD SUITE 117 Newark DE 19711 302-731-4907 Newark
Matthews Bruce General/Family/Pediatric N 1403 SILVERSIDE RD STE A SILVERSIDE PROF
PARK
Wilmington DE 19810 302-475-9220 Wilmington
Matthews Daniel General/Family/Pediatric N 1403 SILVERSIDE RD STE A SILVERSIDE PROF
PARK
Wilmington DE 19810 302-475-9220 Wilmington
Matthias Michael General/Family/Pediatric N 3844 KENNETT PIKE POWDERMILL SQ
SUITE 206
Wilmington DE 19807 302-575-0100 Wilmington
Maxwell Clyde General/Family/Pediatric N 303 LEA BLVD Wilmington DE 19802 302-765-3373 Wilmington
May Betsy General/Family/Pediatric N 850 LIBRARY AVE SUITE 102 Newark DE 19711 302-366-8668 Newark
McAllister Brian General/Family/Pediatric N 200 CLEAVER FARM ROAD SUITE 101 Middletown DE 19709 302-376-0617 Middletown/
Odessa
McAneny Neil General/Family/Pediatric N 625 BARKSDALE RD SUITE 115-117 Newark DE 19711 302-731-4907 Newark
McCann Judith General/Family/Pediatric N 625 BARKSDALE RD, 101 BARKSDALE PROF
CTR
Newark DE 19711 302-368-7463 Newark

Section D - 17 - 9-2008
McKelvey James General/Family/Pediatric N 4901 LIMESTONE ROAD Wilmington DE 19808 302-239-0303 Hockessin Sees
adolescents
12 years and
older
McSpadden H. Dean General/Family/Pediatric N 1801 ROCKLAND ROAD SUITE 204 Wilmington DE 19803 302-654-1242 Wilmington
Medlin Tawana General/Family/Pediatric S 544 S. BEDFORD STREET GEORGETOWN
STATE SERVICE
CENTER
Georgetown DE 19947 302-856-5240 Georgetown DPH Dental
Clinic
Mercer Sean General/Family/Pediatric N 600 NORTH BROAD ST SUITE 7 Middletown DE 19709 302-678-2942 Middletown/
Odessa
Mercer Thomas A. General/Family/Pediatric K 77 SAULSBURY ROAD Dover DE 19904 302-678-2942 Dover
Mercer Thomas W. General/Family/Pediatric K 77 SAULSBURY ROAD Dover DE 19904 302-678-2942 Dover
Mitchell Albert General/Family/Pediatric N 828 N UNION ST Wilmington DE 19805 302-777-4121 Wilmington
Mukkamala Neena General/Family/Pediatric K 95 WOLF CREEK
BOULEVARD

271

SUITE 3 Dover DE 19901 302-734-5303 Dover
Mullen Thomas Oral Surgeon S 8466 HERRING RUN ROAD SUITE D Seaford DE 19973 302-629-3588 Seaford
MummaBoardley
Cynthia General/Family/Pediatric N 1415 FOULK ROAD SUITE 201 Wilmington DE 19803 302-239-1641 Hockessin
Oral Maxillofacial Surgery Oral Surgeon PA P.O.BOX 7777-W5960 Philadelphia PA 19175 215-662-6176 Philadelphia,
PA
Peterson Julie General/Family/Pediatric N 1223 FOULK ROAD Wilmington DE 19803 302-478-8887 Wilmington
Petrunich Raymond Oral Surgeon N 1400 PEOPLES PLAZA SUITE 124 Newark DE 19702 302-836-3565 Newark
Pike Phillip General/Family/Pediatric N 4901 LIMESTONE ROAD Wilmington DE 19808 302-239-0303 Hockessin Sees children
6 years and
older
Pillsbury James General/Family/Pediatric K 125 GREENTREE DRIVE SUITE # 2 Dover DE 19904 302-734-0330 Dover Sees only
referrals from
Dr. Julia
Pillsbury,
pediatrician
Poleck Michael Orthodontist S 1632 SAVANNAH ROAD, SU
6
SUSSEX
ORTHODONTICS
Lewes DE 19958 302-644-4100 Lewes
Poleck Michael Orthodontist N 5501 KIRKWOOD HIGHWAY KIRKWOODMILLTOWN
PLAZA
Wilmington DE 19808 302-999-0111 Wilmington
Rafetto Louis Oral Surgeon N 3512 SILVERSIDE ROAD #12 THE COMMONS Wilmington DE 19810 302-477-1800 Wilmington
Rafetto Ray Orthodontist N 4901 LIMESTONE ROAD Wilmington DE 19808 302-239-4600 Wilmington

Section D - 18 - 9-2008
Ralston William General/Family/Pediatric N 344 E. MAIN STREET NEWARK DENTAL
ASSOCIATES
Newark DE 19711 302-737-5170 Newark
Rautio Erin General/Family/Pediatric N 708 FOULK ROAD Wilmington DE 19803 302-762-6400 Wilmington
Recktenwald William General/Family/Pediatric N 330 CHRISTIANA MEDICAL
CTR
CHRISTIANA
DENTAL CENTER
Newark DE 19702 302-369-3200 Newark
Reddy Veena General/Family/Pediatric N 537 STANTON CHRISTIANA
ROAD
STE 211 Newark DE 19713 302-998-0304 Newark
Roberts Kevin General/Family/Pediatric N 344 E. MAIN STREET NEWARK DENTAL
ASSOCIATES
Newark DE 19711 302-737-5170 Newark
Rocheleau Norman General/Family/Pediatric N 1415 FOULK ROAD SUITE 200 Wilmington DE 19803 302-477-4900 Wilmington
Rodriguez Janette General/Family/Pediatric S 543 SHIPLEY ST SUITE E Seaford DE 19973 302-629-7115 Seaford
Rodriguez Marieve General/Family/Pediatric N GENTLE CARE FAM
DENTISTRY
1021 GILPIN AVE
STE 200
Wilmington DE 19806 302-655-5862 Wilmington
Rohrbaugh Edward General/Family/Pediatric N 5317 LIMESTONE ROAD SUITE 2 Wilmington DE 19808 302-239-6677 Hockessin
Rose Karen General/Family/Pediatric N 446A S. NEW STREET ACCESS DENTAL,
LLC
Dover DE 19904 302-674-3303 Dover
Roseman Barry Oral Surgeon N 708 FOULK ROAD Wilmington DE 19803 302-764-7714 Wilmington
Rosen Michael General/Family/Pediatric N 2601 ANNAND DRIVE SUITE 2 Wilmington DE 19808 302-994-0979 Wilmington
Ryan Michael General/Family/Pediatric N 1415 FOULK ROAD SUITE 201 Wilmington DE 19803 302-378-8600 Middletown/
Odessa
Rybinski John General/Family/Pediatric N 2601 ANNAND DRIVE SUITE 6 Wilmington DE 19808 302-999-9277 Newark
Savani Bhaskar General/Family/Pediatric PA 402 MIDDLETOWN BLVD SUITE 200 Langhorne PA 19047 215-757-4400 Langhorne,
PA
Savani Niranjan General/Family/Pediatric PA 35 B WOODLAND AVENUE ADV FAMILY
DENTISTRY
MORTON PA 19070 610-544-3630 Delaware
County, PA
Savani Niranjan General/Family/Pediatric PA 402 MIDDLETOWN BLVD SUITE 200 Langhorne PA 19047 215-757-4400 Langhorne,
PA
Scanlon Martin General/Family/Pediatric N 5507 KIRKWOOD HIGHWAY Wilmington DE 19808 302-994-3093 Wilmington
Schmitt Margaret General/Family/Pediatric N 1601 CONCORD PIKE Wilmington DE 19806 302-655-1228 Wilmington
Schnelle Marissa General/Family/Pediatric N 4901 LIMESTONE ROAD Wilmington DE 19808 302-239-0303 Hockessin

272

Seitchik Steven General/Family/Pediatric N 1290 PEOPLES PLAZA BEAR-GLASGOW
DENTAL
Newark DE 19702 302-836-3750 Newark
Senholzi Alexis General/Family/Pediatric N 17 POLLY DRUMMOND CTR
102
Newark DE 19711 302-731-0202 Newark

Section D - 19 - 9-2008
Sklut Richard General/Family/Pediatric K 26 WYOMING AVENUE DELMARVA
RURAL MNISTRIES
Dover DE 19904 302-678-2000 Dover
Smith Patricia Pedodontist N COLLINS DENTAL ASSOC 38 PEOPLES PLAZA Newark DE 19713 302-834-4000 Newark
Spera Joe Oral Surgeon N 2101 FOULK ROAD Wilmington DE 19810 302-475-1122 Wilmington
Stiles Marlind General/Family/Pediatric PA 834 CHESTNUT STREET,
STE 311
C/O JUP CNTRL
ENROLLMENTS
Philadelphia PA 19107 215-955-9628 Philadelphia,
PA
Stout Edmond General/Family/Pediatric N 344 E. MAIN STREET NEWARK DENTAL
ASSOCIATES
Newark DE 19711 302-737-5170 Newark
Subach Peter Oral Surgeon N 1601 MILLTOWN ROAD SUITE 17 Wilmington DE 19808 302-995-1870 Wilmington
Syed Sattar General/Family/Pediatric N 5507 KIRKWOOD HIGHWAY KIRKWOODMILLTOWN
PLAZA
Wilmington DE 19808 302-994-3093 Wilmington
Tai Christopher General/Family/Pediatric N 2101 FOULK ROAD STE 201 Wilmington DE 19803 302-477-4900 Wilmington
Taub Daniel Oral Surgeon PA 834 CHESTNUT STREET,
STE 311
C/O JUP CNTRL
ENROLLMENTS
Philadelphia PA 19107 215-955-2440 Philadelphia,
PA
Tetzner Emil Periodontist K 804 S STATE STREET SUITE 1 Dover DE 19901 302-744-9900 Dover
Thomas Glavin Hope General/Family/Pediatric N 5317 LIMESTONE ROAD SUITE 2 Wilmington DE 19808 302-239-6677 Hockessin
University of PA Oral Surgery
Associates
Oral Surgeon PA 3400 SPRUCE STREET 5TH FLOOR WHITE
BLDG.
Philadelphia PA 19104 215-662-6035 Philadelphia,
PA
Usmani Sohaib General/Family/Pediatric N 201 CARTER DR STE A Middletown DE 19709 302-285-7645 Middletown/
Odessa
Usmani Sohaib General/Family/Pediatric N 900 FOULK ROAD STE 203 Wilmington DE 19803 302-778-3822 Wilmington
Vattilana Anthony General/Family/Pediatric N 2309 PENNSYLVANIA
AVENUE
Wilmington DE 19806 302-654-6915 Wilmington
Vaughn Francis Pedodontist N 613 PHILADELPHIA PIKE Wilmington DE 19809 302-764-8000 Wilmington
Vaughn Nadine General/Family/Pediatric N 2018 NAAMANS ROAD SUITE #2 Wilmington DE 19810 302-475-3743 Wilmington
Vickers Susan Pedodontist MD 11029 RACE TRACK ROAD Berlin MD 21811 410-749-0009 Berlin, MD
Wahl Jean General/Family/Pediatric N 1601 CONCORD PIKE Wilmington DE 19803 302-655-1228 Wilmington
Wahl Michael General/Family/Pediatric N 1601 CONCORD PIKE Wilmington DE 19803 302-655-1228 Wilmington
Wahl Patrick General/Family/Pediatric N 1601 CONCORD PIKE Wilmington DE 19803 302-655-1228 Wilmington
Walker Kelly General/Family/Pediatric N 4901 LIMESTONE ROAD SUITE 305 Wilmington DE 19808 302-239-0410 Hockessin

Section D - 20 - 9-2008
Welsh Sharon General/Family/Pediatric N 1400 PEOPLES PLAZA STE 207 Newark DE 19702 302-836-3711 Newark
Westside Health Center General/Family/Pediatric N 1802 W 4TH ST Wilmington DE 19805 302-655-5822 Wilmington
Wieczorek Mark General/Family/Pediatric N 1229 QUINTILLO DRIVE Bear DE 19701 302-838-3384 Bear
Woloshin Neil General/Family/Pediatric N 1290 PEOPLES PLAZA BEAR-GLASGOW
DENTAL
Newark DE 19702 302-836-3750 Newark
Wright Bruce General/Family/Pediatric S 55 ROUTE 24 Lewes DE 19971 302-645-6671 Lewes
Wright Steven General/Family/Pediatric S 55 ROUTE 24 Lewes DE 19971 302-645-6671 Lewes
Wu Lavinia General/Family/Pediatric N 3105 LIMESTONE ROAD SUITE 305 Wilmington DE 19808 302-995-7128 Wilmington
Zaayenga Wayne General/Family/Pediatric PA DEVEREUX FOUNDATION
DENTAL
1300 SHIP ROAD West
Chester
PA 19380 610-431-9651 West
Chester, PA

273

Zawislak Thaddeus General/Family/Pediatric PA 161 E BISSELL AVENUE Oil City PA 16301 814-677-1341 Oil City, PA

Section D - 21 - 9-2008

2. Driver Education
At the beginning of the school year, driver education teachers are required to ask the school
nurse for
assistance in obtaining vision screening results that should be completed within a year prior to
their car
driving hours and also assistance in working with physically and mentally handicapped pupils. A
roster of all driver education pupils will be presented to the school nurse for review with
particular
emphasis on identifying those pupils with extreme visual difficulties including color-blindness,
physical and/or1 mental handicaps. If the nurse is aware of any condition that will affect a pupil’s
ability to drive, he/she should assist the driver education teacher in a follow-up of the case. This
cooperation has been most helpful to the driver education teachers, pupils, parents, and the
Motor
Vehicle Department. The Medical Report of Physician’s findings is on the following pages.
Regulation # 815: Physical Examinations and Screening
This regulation states Driver Education students shall have a vision screening within a year prior
to
their in car driving hours.
http://regulations.delaware.gov/AdminCode/title14/800/815.shtml#TopOfPage
Delaware Code for License qualifications:
http://delcode.delaware.gov/title21/c027/sc01/index.shtml#TopOfPage
Section D - 22 9-2008
DELAWARE DEPARTMENT OF PUBLIC SAFETY
DIVISION OF MOTOR VEHICLES
DRIVER IMPROVEMENT UNIT – MEDICAL RECORDS SECTION
PO BOX 698 - DOVER, DE 19903-0698
Page 1 of 2
MEDICAL REPORT OF PHYSICIAN’S FINDINGS
Name: DOB ____/___/____ License Number
Address:
I hereby authorize Doctor to perform any medical examination necessary
for the purpose of determining my fitness to operate a motor vehicle. Also I understand that this authorization includes permission for
the Director of Motor Vehicles and/or their designee to have this information reviewed by a Medical Board of unidentified physicians
for the purpose of giving him/her a medical opinion on my case for a guidance in determining my medical capabilities to operate a
motor vehicle safely. The information contained in this report is confidential and will be used solely for the purpose of driver’s
license considerations.

Date Signature of Applicant (Required)
(Legibility is a must)
Mental level for reading (circle one) Inadequate – Marginal – Adequate Height:______Weight:______
(A) ORTHOPEDIC AND NEUROMUSCULAR: (Please check as appropriate)
Spastic, Amputations or Ankylosed Joints � YES � NO Joint Ataxia, Paralysis, or Weakness � YES � NO
Prosthetic Devices used for Driving � YES � NO Other Deformities or Abnormalities � YES � NO
If YES to any of the above, please describe:

(B) CARDIO-VASCULAR: (Please check as appropriate)
Strokes – Adams Syndrome � YES � NO Syncope � YES � NO Vertigos � YES � NO
Angina Pectoris � YES � NO Arteriosclerosis � YES � NO Arrhythmia � YES � NO
Cardiac Decompensation � YES � NO Dyspnea � YES � NO Blood Pressure
If YES to any of the above, please describe:

(C) DIABETES: (Please check as appropriate)
Is he/she a known diabetic? � YES � NO Status of Control
Duration: Diabetic Acidosis � YES � NO
If YES to any of the above, please describe:
(D) HEARING: Normal? � YES � NO If NO, please describe:

274

(E) DRUGS AND/OR ALCOHOL: (Please check as appropriate)
Any objective evidence or personal knowledge of addiction, habituation, or alcoholism? � YES � NO
If YES, please explain:

Section D - 23 9-2008
Page 2 of 2 Patient Name: DOB:____/___/____

(F) PSYCHOLOGICAL ASSESSMENT: (Please check as appropriate)
Is there any evidence of emotional instability? � YES � NO Is further examination suggested? � YES � NO
Does he/she have or has he/she had any episodes of conditions listed below?
Mental Clouding � YES � NO Blackouts � YES � NO Dizziness � YES � NO
Unconsciousness � YES � NO Convulsions � YES � NO
If YES to any of the above, please explain nature and date of last episode:
Diagnosis:
(G) Does he/she have any other condition or diseases which would decrease ability to safely operate a motor vehicle?
(Please check as appropriate) � YES � NO
If YES, please explain:
(H) What type(s) and quantities of drugs are being prescribed for the patient?
(I) Do any of the above medications affect driving ability? (Please check as appropriate) � YES � NO
If YES, please explain:
(J) From a medical standpoint, do you feel he/she is capable of operating a vehicle safely? � YES � NO
If NO, please explain:

If YES, the treating physician must attest to one of the two below listed statements, as may be applicable, for any
person who is subject to loss of consciousness due to disease of the central nervous system.
� I hereby certify that I am the treating physician duly, licensed to practice medicine and surgery, for the above named individual
and that I have been the treating physician for him/her for a period of at least three months, that I am aware of his/her medical history,
including his/her history with respect to diseases of the central nervous system, and that such person’s infirmity is under sufficient
control to permit him/her to operate a motor vehicle with safety to person and property.
� I hereby certify that I am the treating physician, duly licensed to practice medicine and surgery, for the above named individual
and that I have been the treating physician for him/her for a period of at least three months, that I am aware of his/her medical history,
including his/her history with respect to diseases of the central nervous system, and that such person’s disease no longer requires
treatment and that such person can reasonably expect to suffer no further losses of consciousness on account of such disease.
(K) How long have you been treating this patient? Date of last examination:_____/____/_____
(L) Additional comments:
Physician’s Name (Printed or typed) Physician’s Signature
Address Phone Number

Date:
Please mail form to: MEDICAL RECORDS SECTION – DRIVER IMPROVEMENT UNIT – PO Box 698 – Dover, DE 19903-0698
The form may be transmitted by facsimile to: (302) 739-5667 ATTN: MEDICAL RECORDS SECTION
FORM MV-346 Document No. 45-07-93-03-01

Section D - 24 - 9-2008

3. Health Education
Effective health education curricula should reflect the growing body of research that emphasizes
teaching functional health information (essential concepts); shaping personal values that support
healthy behaviors; shaping group norms that value a healthy lifestyle; and developing the
essential
health skills necessary to adopt, practice, and maintain health–enhancing behaviors. Less
effective
curricula often overemphasize teaching scientific facts and increasing student knowledge. CDC
identifies the characteristics of effective health education curricula at:
www.cdc.gov/HealthyYouth/SHER/characteristics/index.htm
Delaware Health Education Standards
1. Students will understand essential health concepts in order to transfer knowledge into healthy
actions for life.
2. Students will analyze the influence of family, peers, culture, media, technology and other
factors on
health behaviors.
3. Students will demonstrate the ability to access information, products and services to enhance
health.

275

4. Students will demonstrate the ability to use interpersonal communication skills to enhance
health
and avoid or reduce health risks.
5. Students will demonstrate the ability to use decision-making skills to enhance health.
6. Students will demonstrate the ability to use goal-setting skills to enhance health.
7. Students will demonstrate the ability to practice health-enhancing behaviors and avoid or
reduce
health risks. (self-management)
8. Students will demonstrate the ability to advocate for personal, family and community health.
Regulation # 851: K-12 Comprehensive Health Education Program
This regulation mandates the program requirements for Health Education in schools.
http://regulations.delaware.gov/AdminCode/title14/800/851.shtml#TopOfPage
Resources:
• DDOE’s Health Education webpage and resources:
http://www.doe.k12.de.us/programs/ci/cont_areas/health.shtml
• Health Teacher - A K-12 health curriculum that delineates knowledge and skill expectations
that are consistent with the Assessment Framework and National Health Education Standards
for each grade level: www.healthteacher.com
• Nemours Foundation – Kidshealth: www.kidshealth.org
Section D - 25 - 9-2008

4. Nutrition
The health and well-being of children is directly impacted by their overall nutritional status. The
types
of foods eaten and the meal patterns are linked to both academic performance and the overall
long term
health. Poor nutrition and inactivity can negatively impact both academics and social skills
among
students. Breakfast is often described as the most important meal of the day, but many students
do not
eat anything before classes begin each day. Children who eat breakfast show improved cognitive
function, attention, and memory. Participating in school breakfast can attract children to school,
improve standardized achievement test scores, and lower absence and tardiness rates.
Childhood obesity is an ever increasing problem in schools across America. Delaware is no
exception
with 36% of the students classified as overweight or at-risk to be overweight (Nemours.org).
Childhood obesity is not just a health issue, it also impacts academic achievement and social and
emotional health. To help reverse current trends schools need to consider modified and/or new
approaches to partnering with communities, families and students. Quality school nutrition
programs,
the availability of healthy snacks in vending machines and policies that eliminate the sale of junk
foods
for fund raisers are all basic steps that districts and schools can adopt. Nationally, it is recognized
that
schools did not create the obesity epidemic; however, it is also recognized that schools present
the
greatest opportunities for systemic solutions as a vested stakeholder. The U.S. Department of
276

Education has produced a list of effective strategies to help stakeholders target behaviors that
lead to
improve health. These strategies include: making healthy foods more readily available,
influencing
food and beverage contracts to require healthy items only, developing comprehensive wellness
policies, increasing opportunities to teach nutrition education and offering physical activity in
afterschool
programs, making physical activity and nutrition a part of every day life, creating fundraising
activities and student reward programs that support health, and developing nutrition standards for
the
entire school environment . The U.S. Department of Education also provides research based
documentation that supports the effectiveness of these strategies. Students will purchase healthy
foods,
parents and staff can influence behavior, and schools can make maintain or increase revenues
with
healthy foods selections. Even though healthy food choices are sometimes more expensive, data
shows
that revenues will more than support the increased costs. Delaware has regulatory requirements
to
ensure quality programs and participates in USDA programs that provide healthy meals and
snacks to
children.
Regulation #852: Child Nutrition
This regulation mandates child nutrition policies in schools.
http://regulations.delaware.gov/AdminCode/title14/800/852.shtml#TopOfPage
Resources:
• Action for Healthy Kids: www.actionforhealthykids.org
• Food Research and Action Center: www.frac.org
• Nemours Foundation: www.nemours.org/department/nhps.html
• School Nutrition Association (Includes self-assessment tool): www.asfsa.org
• United States Department of Agriculture (USDA) Food and Nutrition: www.usda.gov
Section D - 26 - 9-2008

5. Physical Activity
Physical activity is any bodily movement produced by skeletal muscles that result in an
expenditure of
energy.* Physical activity has both benefits and risks. Regular physical activity promotes
cardiovascular health. The benefits of exercise are related to frequency, intensity and duration.
Planning for physical activity needs to consider a variety of factors, including personal fitness
levels,
overcoming barriers and protecting the body from exposure to the elements. The use of proper
protective equipment helps prevent injuries during certain activities. The most widely accepted
recommendation is for children to accumulate at least 60 minutes of physical activity on all or
most all
days of the week, both in and out of school.
Quality physical activity programs promote the physical growth and development of children and

277

youth while contributing to their general health, well-being, and fitness. Physical activity events
that
include families and collaborate with community members directly relate in an interactive
manner with
the other areas and domains addressed by Connections to Learning. Constructive use of time,
including leisure hours, keeping fit and enjoying physical forms of recreation during the school
years
and continuing throughout adult life is addressed.
Physical activity is critical to the development and maintenance of good health. A goal of
Physical
Education is to develop physically educated individuals who have the knowledge and skills to
enjoy a
lifetime of healthful physical activity. Physical activities can promote each student’s optimum
physical, mental, emotional and social development when utilized with the proper nutritional,
and
other protective factors. Physical activity is paramount in addressing mobility, stamina, and
student
attention span; thus, improving the level of academic success.
Resources and Citations:
• “Comprehensive School Physical Activity Programs” A Position Statement from the National
Association for Sport and Physical Education, © May 2008 National Association for Sport and
Physical Education, an association of the American Alliance for Health, Physical Education,
Recreation and Dance; http://iweb.aahperd.org/naspe/
*CCSSO SCASS Health Education Assessment Project © 1998
Fitnessgram
In 2006, Delaware House Bill 372 was passed requiring each school district and charter school to
assess the physical condition of each student at least once in grades K-5, 6-8 and 9-12 with
results to
be provided to parents, guardians or relative caregivers. House Bill 471 created a pilot program
to
determine the best practices and assessment that could be implemented in schools statewide for
physical education/physical activity. The Fitnessgram was chosen by the DDOE the assessment
tool
for determining the physical fitness of each student. Learn more about the Fitnessgram and
DDOE’s
physical education resources at:
http://www.doe.k12.de.us/programs/ci/content_areas/phys_ed_resources.shtml
Section D - 27 - 9-2008

B. School Climate
Overview
The CDC describes a healthy school environment as: “The physical and aesthetic surroundings
and the
psychosocial climate and culture of the school. Factors that influence the physical environment
include
the school building and the area surrounding it, any biological or chemical agents that are
detrimental
to health, and physical conditions such as temperature, noise, and lighting. The psychological
278

environment includes the physical, emotional, and social conditions that affect the well-being of
students and staff.”
The goal of School Climate and Discipline programs in Delaware is to promote necessary
components
of a healthy school climate: to support learning and contribute to students’ health by minimizing
distractions and physical, psychological, and social hazards; to create a climate in which students
and
school staff do their best work; to expect that all students can succeed; and to implement
supporting
policies. This goal is accomplished by having in place collaborative relationships, an effective
evaluation process, technical assistance and resources to ensure that schools are designed to
provide a
safe, healthy, and supportive environment that fosters learning.
School climate relates to the Connections to Learning process. Strategies to improve the school
climate
by teaching conflict resolution and social skills can also be multi-tiered and include curriculum
with
teaching and modeling positive social interactions. Schools that implement programs such as
Positive
Behavior Support (PBS) incorporate proactive strategies at the building, class, and individual
level.
Schools whom adopt PBS establish a safe school climate that promotes academic, social, and
emotional development. Other strategies and tools include the Delaware School Climate Survey,
an
evaluation measure given to parents, school staff, and students to examine the needs and
effectiveness
of efforts to improve school climate. Using such an evaluation measure, allows all parties
involved in
the school to give input about the practices and environment of the school and will in turn, help
foster a
positive school climate. A positive school climate can also include anti-bullying strategies and
drop out
prevention that can be implemented at any age level.
Resources:
• DDOE’s School Climate and Discipline webpage:
http://www.doe.k12.de.us/programs/climate/default.shtml
• Positive Behavior Support: www.pbis.org
• National Drop-out Prevention Network: www.dropoutprevention.org
• Delaware Positive Behavior Support: www.delawarepbs.org
• Delaware School Climate Survey: www.udel.edu/cds/pbs/survey.html
Section D - 28 - 9-2008

1. School Crisis Plans/Emergency Preparedness
School Nurses should be included in emergency planning and disaster preparedness in schools to
ensure every student has the same opportunity for effective management and stabilization of
likely

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emergencies at school. Students who have special health care needs are at greater risk for a
medical
emergency and they should have an individualized Emergency Care Plan (NASN, 2008).
There are checklists and guidelines from DDOE for school emergency preparedness. According
to the
DDOE Regulation # 620, all schools must have plans and review and exercise them annually.
These
guidelines represent an all hazards approach and include any emergency event, including a major
communicable disease event such as a Pandemic Influenza Outbreak that may occur in the
school
community.
Regulation # 620: School Crisis and Response Plans.
This regulation discusses the requirements of school crisis and response plans.
http://regulations.delaware.gov/AdminCode/title14/600/620.shtml#TopOfPage
Resources:
• American Red Cross: http://www.redcross.org/
• DDOE’s DE School Climate and Discipline webpage:
http://www.doe.k12.de.us/programs/climate/default.shtml.
• Delaware Emergency Management Agency (DEMA): http://dema.delaware.gov/
• Delaware Health and Social Services School Preparedness page:
http://dhss.delaware.gov/dhss/dph/php/prepschool.html
• Disaster Preparedness: School Nurse Role: http://www.nasn.org/Default.aspx?tabid=221
• Emergency Care Plans for Students with Special Health Care Needs:
http://www.nasn.org/Default.aspx?tabid=220
• FEMA for Kids – Federal Emergency Management Agency (FEMA):
http://www.fema.gov/kids/
• Facing Fear: Helping Young People Deal with Terrorism and Tragic Events – Red Cross
Curriculum: http://www.redcross.org/disaster/masters/facingfear/
• Masters of Disaster- Red Cross Disaster Preparedness Curriculum:
http://www.redcross.org/services/prepare/0,1082,0_63_,00.html
• Preparing for School Emergencies: http://www.nasn.org/Default.aspx?tabid=238
Section D - 29 - 9-2008

2. Staff Wellness/ Back Protection
Staff Wellness
School Nurses play a vital role in Staff Wellness including health promotion and disease
prevention.
Chronic diseases have both direct and indirect costs on work productivity and absenteeism of
both staff
and students. A school environment has its own set of health risks, including those social and
emotional components that can take a toll on the overall climate of the school and the spirit of
the staff
(NASN, 2008). Healthy staff role models have been shown to influence the health of students.
Resources:
• The National Association of School Nurses issue brief on Health Promotion and Disease
Prevention: http://www.nasn.org/Default.aspx?tabid=271
Back Protection
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Caring for students may require having to move or lift them. It is important to use proper
technique to
protect your back to prevent injury. OSHA (U.S. Department of Labors Office of Safety and
Health
Administration) defines Ergonomics as:
“Ergonomics is the science of fitting the job to the worker. When there is a mismatch between
the
physical requirements of the job and the physical capacity of the worker, work-related
musculoskeletal
disorders (MSDs) can result. Ergonomics is the practice of designing equipment and work tasks
to
conform to the capability of the worker, it provides a means for adjusting the work environment
and
work practices to prevent injuries before they occur. Health care facilities especially nursing
homes
have been identified as an environment where ergonomic stressors exist.”
(www.osha.gov/SLTC/etools/hospital/hazards/ergo/ergo.html)
Section D - 30 - 9-2008
Remember to Protect Your Back*
Factors Contributing to Back Pain
• Stress
• Poor nutrition
• Poor body mechanics
• Poor posture
Seven Rules to Lifting
• Plan the lift.
• Face the load.
• Lift with legs.
• Get as close to the load as possible.
• Come full upright.
• Pivot, don't twist or jerk as you lift.
• Seek assistance if someone else is available.
Back Exercises
Our backs work very hard all throughout the day. The exercises are designed to strengthen your lower back and encourage
flexibility of
your spine.
1. PELVIC TILT
Lay on your back with knees bent. Flatten your lower back as if you are trying to make every single vertebra touch the floor.
Pull in abdominal muscles.
2. KNEE TO CHEST
Begin as in #1, on your back with your knees bent. Bring one leg up to your chest and hold. Let it down slowly and repeat
with other leg.
3. DOUBLE KNEE TO CHEST
Begin as in #1, on your back with your knees bent. Bring both legs up to your chest, hold your knees. Slowly raise your head
and hold for count of 5, slowly lower your head and legs.
4. PRONE KNEELING
Begin on your hands and knees. Lower your head and arch your back toward the ceiling, as a cat stretches.
*Exercises developed with the assistance of Alison Malone, R.P.T. and Sam Cronis, R.P.T. Taken from earlier Delaware School
Nursing
Manual.

Section D - 31 - 9-2008

3. Recommended Space and Supplies/Equipment in Nurse’s Office
Recommended Space Allotments for Health Room
School Construction Formula – Space Allowances*
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(Given in Square Feet)
Senior High School and Middle School
Number of Students 500 700 1000 1200 1600
Health/Nurse/Wellness 2,200 2,200 2,300 2,400 2,400
Elementary School
Number of Students 480 600 720 840
Health/Nurse 800 900 900 900
Planning the Health Suite
The nurse is often asked to assist in planning the health suite during renovation or construction of
a new school.
Some suggestions:
1. Use the responsibilities of the school nurse as outlined in the job description to plan the
facilities.
2. Plan jointly with other personnel (guidance, speech and hearing) working closely with the
school
nurse, in order to best utilize the floor space.
3. The recommended space allotments are indicated.
4. The sound-treated room should be planned for use in other activities rather than limited to
audiometric screening and threshold testing. The room should be placed in the elementary
school since screening is recommended for grades K, 2, 4, 7 and 9 (or 10).
5. The facility should be close to the administrative section with exit to outside, if possible, for
easy
accessibility.
6. Contact the State Supervisor of Health Services for assistance.
* From – Building Quality Schools: Revisions to the School Construction Formula and
Recommendations on
Standards, School Construction Planning Committee: Report and Recommendations, October
2002. Available
at:
www.dspace.udel.edu:8080/dspace/bitstream/19716/39/1/building_quality_schools.pdf
Section D - 32 - 9-2008
Tentative List of Supplies for School Health Services
NOTE: When ordering supplies, consideration should be given to the unique needs of the students and staff. For
example, a
glucometer, suction machine or specific-sized oxygen mask may be needed for a given school year.
Supplies Items per school based on rated student capacity
500 700 1,000 1,200 1,600
Adhesive Tape, 2” x 5 yd. 3 5 6 7 8
Alcohol
rubbing 15 oz. bottle 5 6 8 8 9
dispenser, plastic 1 1 1 1 1
Antibacterial ointment 1 1 1 1 1
Applicators, wood (72 doz. 1 box) 1 1 1 2 2
Bags, plastic, zipper type, packages 6 8 10 12 14
Band Aids 100’s ¾” 6 8 11 14 17
Bandage
elastic 2” (Ace) 2 2 4 4 5
elastic 3” (Ace) 2 2 4 4 5
elastic 6” (Ace) 2 2 3 3 3
gauze 1” 6 7 8 10 10
gauze 1 ½” 6 7 8 12 12

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gauze 2” 6 7 10 12 13
Bleach, 1 gallon 1 1 1 1 1
Cotton balls (5000 per box) 1 1 1 2 2
CPR
mask, adult 1 1 1 1 1
mask, child 1 1 1 1 1
airway 1 1 1 1 1
Dental floss 1 1 1 1 1
Diphenhydramine liquid (ex. Benadryl), dye-free 1 1 1 1 1
Drinking cups, 4 oz. 1000’s 5 6 9 11 14
Epinephrine, injectable (doctor/standing order required) 1 1 1 1 1
Exam table, paper 18” x 24” pkg. 1 1 1 2 2
Gauze
pads, 2” x 2” box 100 1 1 1 2 2
pads, 2” x 2” box 100, non-stick 1 1 1 2 2
Gauze continued:
pads, 3” x 3” box 100 1 1 1 2 2
pads, 3” x 3” box 100, non-stick 1 1 1 2 2
roll, 4” wide, 15 yds. 1 1 1 1 1
Gloves, examination, non-latex 5 bx 7 bx 10 bx 12 bx 16 bx
Glucose Gel 1 1 1 1 1
Hydrogen Peroxide 3 3 4 4 5
Ice bag 1 1 1 1 1
Ipecac 1 1 1 1 1
Kleenex, box 9 12 14 16 20
Medicine cups, 100 3 3 3 4 4
Oxygen, with mask/cannula (doctor/standing order required) 1 1 1 1 1
Safety pins, mixed sizes 1 1 1 1 1
Saline 3 3 4 4 5
Sanitary pads, box 24 (age appropriate) 4 4 5 5 6
Sheeting, paper 18” x 24” pkg. 1 1 1 2 2
Slings, appropriate sizes 2 2 2 2 2
Soap, liquid 16 oz. bottle 6 7 8 10 12
Splints 3 3 3 3 3
Sterile water, 1 gallon 1 1 1 1 1
Thermometers, sheaths 1 1 1 1 1
Tongue depressors 1 1 1 2 2
Vaseline 1 1 1 1 1
Wax, dental 1 1 1 1 1

Section D - 33 - 9-2008
Tentative List of Durable Equipment for School Health Services
Equipment Items per school
Audiometer 1
Basin 1
Blanket, twin 2
Bucket, plastic, utility 1
Cabinet, medicine with lock 1
Cabinet – built around the sink 1
Chairs (side chairs) 6
Computer, with internet access 1
Couch (plastic) 1
Desk 30” x 55” 1
Desk Chair 1
Drinking cup dispenser (optional) 1
Eye chart or vision screening machine 1
Eye cup 1
Examination table 1
File cabinet – 4 drawer 1
File drawer for 3 x 5 cards 1
Flashlight/penlight 1
Glasses repair kit 1
Heating pad 1

283

Lamp, gooseneck type 1
Magnifying lamp with light 1
Mask 1
Mirror 1
Mouthshield 1
Nebulizer 1
Ophthalmoscope 1
Otoscope with disposable probes 1
Peak Flow meter with disposable mouthpieces 1
Pencil sharpener 1
Pill
Cutter 1
Counter 1
Crusher 1
Pillow 2
Reference books
Control of Communicable Diseases Manual 1
Pharmacological reference 1
School nursing/pediatric textbook 1
Refrigerator and water cooler combination 1
Sanitary waste can 1
Scales, with measuring aid 1
Scissors, bandage 1
Screen, folding 1
Soap dispenser 1
Sphygmomanometer (non-mercury) with cuff 1
Pediatric cuff 1
Adult cuff 1
Large adult cuff 1
Stethoscope 1
Stretcher 1
Tables, small student-type 2
Tables, utility, 3 x 5 ft. 1
Thermometers (non-mercury) 2
Tweezers, for removing splinters 1
Waste basket, standard 1
Wheelchair 1

Section D - 34 - 9-2008

C. Social and Emotional Health
Overview
Social-emotional development and academic achievement represent a continuum of development
that is needed
for all children to grow up healthy and succeed in school and life. Children’s excitement for
learning, self
concept, relationship with peers and adults, capacity to cooperate and manage themselves are
components that
lead to academic success.
Schools have the responsibility to support the intentional development of positive child-adult
relationships and
provide environments that allow all children to succeed. Intensive interventions are paramount
for vulnerable
children—those with language, economic, and other hardships that place obstacles to social
development and
academic success.
“It is the position of the National Association of School Nurses (NASN) that mental health is as
critical to
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academic success as physical well-being. School nurses play a vital role in the school community
by promoting
positive mental health development in students through school/community-based programs and
curricula. As
members of interdisciplinary teams, school nurses play a vital role in supporting early
assessment, planning,
intervention, and follow-up of children in need of mental health services. In addition, school
nurses serve as
advocates, facilitators and counselors of mental health services both within the school
environment and in the
community”.
(NASN, 2008 http://www.nasn.org/Default.aspx?tabid=231.)
Included in this section are a variety of resources and programs that foster positive social
and emotional
health.
Section D - 35 - 9-2008

1. Caregiver’s Law
Caregiver’s: School and Medical Authorization Affidavits
What is the Caregivers’ Law?
(School – 14 Del. Code § 202-203, medical – 13 Del. Code § 707-708)
The Caregivers’ School Authorization law (13 Del. Code §§ 202, 707, 708, see Section A) allows
a caregiver,
raising a relative’s child without custody or guardianship, to register that child for school. The
Caregivers’
School Authorization law applies to all public schools in Delaware without exception.
What is the difference between a School and Medical Authorization Affidavit?
When properly completed and notarized, both Affidavits allow a relative caregiver who does not
have custody
or guardianship of a child to register that child for school and to approve his or her medical
treatment. Since
these Affidavits are part of the Delaware Code, all public schools and providers of medical care
must accept
them. In some circumstances a parent, custodian, or guardian may sign the Affidavit permitting
the caregiver to
take medical or school responsibilities for the child.
Where can one get a copy of the Affidavits?
The Caregivers’ School Authorization Affidavit is available at all school district offices. The
Caregivers’
Medical Authorization Affidavit is available at many State Service Centers and all Public Health
sites that
provide health services. Samples of both Affidavits are available on-line at the Division of
Services for Aging
and Adults with Physical Disabilities’ (DSAAPD) web site www.dhss.delaware.gov/dsaapd
under “Support for
Grandparents Raising Children”.
What responsibilities does the Caregivers’ School Authorization affidavit place on the
caregiver?
285

Once the affidavit completed and approved by the school district, the caregiver is responsible for
enrolling the
student in school, being the legal contact for the school regarding, but not limited to, truancy and
discipline,
making school-based decisions, regarding but not limited to special education; and giving
medical approval for
health care administered by the school.
How long can the Caregivers’ School Affidavit be used?
The School Affidavit can be renewed for up to two years of school or longer if the school
district decides it is
appropriate. After two years the caregiver is required to begin filing legal papers for
guardianship.
The Medical Affidavit is valid for one year from the date it is notarized and may also be
renewed. For more
information contact your school district office or the Division of Services for Aging and Adults
with Physical
Disabilities at 1-800-223-9074, on-line at www.dhss.delaware.gov/dsaapd, or via internet e-mail
at
[email protected]
Section D - 36 - 9-2008

2. Child Abuse and Neglect
School nurses and any school employee, who in good faith suspect child abuse or neglect, are
mandated to
report it immediately. This includes whenever there is reasonable cause to know or to suspect
that a child has
been subjected to abuse or neglect, or if there has been observation of a child being subjected to
circumstances
or conditions which would reasonably result in abuse or neglect. Keep in mind that it is not the
responsibility of
the reporter to prove that the child has been abused or neglected. Once a suspicion exists, the
nurse (or staff
member) should not engage the child in any interviewing or questioning. It is the responsibility
of the Division
of Family Services (DFS) to investigate the case, determine if abuse or neglect has occurred or if
the child is at
risk of being abused or neglected, and make a decision whether follow-up services are needed. In
accordance
with 16 Del. C, § 903 and 904 an oral report should be made to the Report Line at the national
Toll Free 24Hour Report Line 1-800-292-9582. The phones are answered 24 hours a day, 365 days a year by
Division of
Family Services’ staff. Within 72 hours after the oral report, a completed Child Abuse/Neglect
Mandatory
Reporting Form should be mailed (to address on form). Care should be taken to only record facts
and physical
findings. School staff should not photograph a child’s injuries. Only DFS or the police should
take photographs
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as they have specialized training to do so. Additionally, schools should not notify parents that
they made a
report. All information is to remain strictly confidential.
When you call in a report, be prepared to provide the following information, if known. A lack of
information
does not mean that DFS will not accept the report, but more information will assist DFS in
making a decision
about the urgency of the needed response.
• Name, age (date of birth if possible), gender of the child and other family members and the
names of
the parents/caretakers if available
• Address, phone numbers, and/or directions to the family’s home or location of the child
• Description of the suspected abuse or neglect
• Current condition of the child (e.g., whether medical treatment appears necessary)
• Any other pertinent information which may assist DFS in investigating abuse or neglect
When making a report you will not have to give your name (anonymous report); however, if you
do give your
name it will allow the caseworker to call you for further information about the family and you
will have
documentation that you have followed the mandatory reporting law. By Delaware statute, there is
no liability
for making a report. It is DFS policy to never divulge the name of the reporter without the
reporter’s consent
or, as required federally, to cooperate with investigatory entities such as law enforcement or the
Department of
Justice.
Once a report is received, the Report Line worker will review the facts of the case with a
supervisor. In most
instances, you will be informed at the conclusion of making the report that if you do not receive
a call back, the
report was accepted for investigation after supervisory review. If a decision is made not to
investigate, you will
be contacted by Report Line staff. If you have additional information or believe strongly that the
case should be
investigated, you should ask to speak to the Report Line Supervisor for further discussion.
Section D - 37 - 3-2009

Child Abuse and Neglect Statutes:
• Child Abuse and Neglect Definitions, Title 10, Chapter 9, Subchapter 1
• Title 11, Chapter 4, Subsection 468 (Delaware General Assembly website)
• Title 16, Chapter 9, Subchapter I. Reports and Investigations of Abuse and Neglect; Child
Protection
Accountability Commission (Delaware General Assembly website)
• Title 16, Chapter 9, Subchapter II, Subsections 921 -929 (Delaware General Assembly
website)
Child Protection Registry Information

287

• Mandatory Child Abuse and Neglect Reporting form. All persons are required by law to report
child
abuse or neglect. * Please note, a call to the Reportline must be accomplished when using this
form.
[2pg] PDF format Revised 2007, 2p, 417kb
• DSCYF/School District Program Collaboration Matrix [rev. 08/28/2002, 6pg]
PDF format 121kb
• State of Delaware Domestic Violence Advocate Pilot Project 2002-2004: An Overview and
Evaluation
PDF format (12/14/2004, 50p, 482k)
• The Professionals' Guide to Reporting Child Abuse and Neglect
• A DSCYF Division of Family Services brochure.[25pg] PDF format 622kb
• Parent Handbook / Manyèl pou paran / Manual de los Padres
This handbook was designed with parents in mind. It is intended to provide an overview of our
services
and should answer many common questions. Your caseworker can explain and provide answers
to
questions you may have which do not appear in this handbook.
o Creole version:PDF format [05/2004, 11pg, 256kb]
o English version:PDF format [05/2004, 11pg, 256kb]
o Spanish version:PDF format [05/2004, 11pg, 256kb]
o French version:PDF format [08/22/2005, 12pg, 208kb]
Section D - 38 - 9-2008
Physical and Behavioral Indicators of Child Abuse and Neglect
Obtained from the Department of Services for Children, Youth and Their Families
Type CA/N Physical Indicators Behavioral Indicators
Physical Abuse Unexplained bruises and welts:
• on face, lips, mouth
• on torso, back, buttocks, thighs
• in various stages of healing
• clustered, forming regular patterns
• reflecting shape of article used to inflict
(electric cord, belt buckle)
• on several different surface areas
• regularly appear after absence, weekend or
vacation
Unexplained burns:
• cigar, cigarette burns, especially on soles,
palms, back or buttocks
• immersion burns (sock-like, glove-like,
doughnut shaped on buttocks or genitalia)
• patterned like electric burner, iron, etc.
• rope burns on arms, legs, neck or torso
Unexplained fractures:
• to skull, nose, facial structure
• in various stages of healing
• multiple or spiral fractures
Unexplained lacerations or abrasions:
• to mouth, lips, gums, eyes
• to external genitalia
Wary of adult contacts
Apprehensive when other children cry
Behavioral extremes:

288

• aggressiveness, or
• withdrawal
Frightened of parents
Afraid to go home
Reports injury by parents
Physical
Neglect
Consistent hunger, poor hygiene, inappropriate dress
Consistent lack of supervision, especially in dangerous
activities or long periods
Unattended physical problems or medical needs
Abandonment
Begging, stealing food
Extended stays at school (early arrival and late departure)
Constant fatigue, listlessness or falling asleep in class
Alcohol or drug abuse
Delinquency (e.g. thefts)
States there is no caretaker
Sexual Abuse Difficulty in walking or sitting
Torn, stained or bloody underclothing
Pain or itching in genital area
Bruises or bleeding in external genitalia, vaginal or anal
areas
Venereal disease, especially in pre-teens
Pregnancy
Unwilling to change for gym or participate in physical
education class
Withdrawal, fantasy or infantile behavior
Bizarre, sophisticated, or unusual sexual behavior or
knowledge
Poor peer relationships
Delinquent or run away
Reports sexual assault by caretaker
Emotional
Maltreatment
Speech disorders
Lags in physical development
Failure-to-thrive
Habit disorders (sucking, biting, rocking, etc.)
Conduct disorders (antisocial, destructive, etc.)
Neurotic traits (sleep disorders, inhibition of play)
Psychoneurotic reactions (hysteria, obsession, compulsion,
phobias, hypochondria)
Behavior extremes:
• compliant, pensive
• aggressive, demanding
Overly adaptive behavior:
• inappropriately adult
• inappropriately infant
Developmental lags (mental, emotional)
Attempted suicide

Section D - 39 - 3-2009

MEMORANDUM OF UNDERSTANDING
BETWEEN
THE DEPARTMENT OF EDUCATION/PUBLIC SCHOOL
DISTRICTS AND THE DEPARTMENT OF SERVICES FOR CHILDREN,
YOUTH AND THEIR FAMILIES – DIVISION OF FAMILY SERVICES
A Memoranda of Understanding exists that describes specific reporting procedures, protocol for

289

interaction between agencies, criteria for sharing of information, problem resolution and
designate
liaisons for each agency. A statewide committee has convened to update the MOU.
Link to MOU
Section D - 40 - 9-2008

3. Domestic Violence
Domestic violence is a pattern of assaultive and coercive behaviors, including physical, sexual,
and
psychological attacks, as well as economic coercion, that adults or adolescents use against their
intimate partners. Examples of domestic violence are physical assault, sexual assault,
psychological
assault, economic coercion and using children to control an adult victim.
Domestic violence is a learned behavior. It is learned through observation,
experience/reinforcement,
in the family, communities (schools, peer groups, etc.) and culture. It is not caused by genetics,
illness,
alcohol and drugs, anger, stress and behavior of the victim or problems in the relationship.
Domestic violence has a great effect on children of all ages. An important resource in Delaware
is The
Domestic Violence Coordinating Council (DVCC). This state agency was legislatively created
in
1993 to improve Delaware’s response to domestic violence. Information about the Council, its
activities and other resources is available on the DVCC website at www.dvcc.delaware.gov.
Facts on Children Witnessing Domestic Violence
Domestic violence is a pattern of assaultive and coercive behaviors, including physical, sexual,
and
psychological attacks (including stalking) that adults or adolescents use against their intimate
partners.
Domestic violence is a learned behavior. It is learned through observation,
experience/reinforcement
in the family, communities (schools, peer groups, etc) and culture. It is not caused by genetics,
illness,
alcohol and drugs, anger, stress, the behavior of the victim or problems in the relationship.
Seeing or hearing violence among family members hurts children in many ways. In general,
children
can experience a sense of danger, chaos, confusion, anxiety, isolation, fear, tension, and/or
hopelessness. They do not have to be hit to feel the pain of violence. Children who witness
domestic
violence are at special risk for emotional and developmental problems.
Children growing up witnessing domestic violence may perpetuate violence in their adolescent
relationships.
An important resource in Delaware is the Domestic Violence Coordinating Council (DVCC).
This
state agency was legislatively created in 1993 to improve Delaware’s response to domestic
violence.
Information about the Council, its activities and other resources is available on their web site:
www.dvcc.delaware.gov.
290

FREQUENTLY ASKED QUESTIONS
1. How does domestic violence impact the health of victims and their children? How do
healthcare
professionals screen for domestic violence?
• Facts on Healthcare and Domestic Violence, and Children and Domestic Violence: Family
Violence Prevention Fund www.endabuse.org. (DVCC Link)
• Children and Domestic Violence Bulletin for Professionals: Child Welfare Information
Gateway www.childwelfare.gov/pubs/factsheets/domesticviolence
Section D - 41 - 9-2008

2. How can victims prepare to leave an abusive relationship?
Victims should contact the 24 hour Domestic Violence Hotlines for Safety Planning:
Kent and Sussex Counties New Castle County
Northern Kent: (302) 678-3886 (302) 762-6110
Kent and Sussex: (302) 422-8058
Bi-Lingual: (302) 745-9874 (Spanish)
3. Where can victims or offenders find help in Delaware?
• Catholic Charities, Inc.: (302) 655-9624 (New Castle)
• Child, Inc.: (320) 762-8989 (New Castle)
• Crossroads of Georgetown: (302) 855-1230, x-106 (Sussex) (Offers Programs in Spanish)
• People’s Place II: (302) 424-2420 (Kent and Sussex)
• Family Advocacy Program: (302) 677-2711 (Kent) (For Military Families)
4. What can organizations do to address domestic violence?
Toolkit to End Violence Against Women and Community Model Programs for Domestic
Violence:
United States Department of Justice
http://www.ojp.usdoj.gov
5. How does domestic violence affect children?
• National Center for Children Exposed to Violence (NCCEV) Child Study Center, Yale
University School of Medicine www.nccev.org/us (Click on Parent Directory then click on
Children and Violence).
• Family Violence Prevention Fund: www.endabuse.org
6. Can a teen experiencing dating violence file for protection in Delaware?
• Yes. Parents or guardians of teens who are (or have been) in an abusive relationship can
file for protection in Family Court on behalf of their child.
• Understanding the Protection from Abuse Process www.courts.delaware.gov (Click on
Family Court then click on Protection From Abuse)
7. Is teen dating violence different from adult domestic violence?
www.womenslaw.org (Click on Learn About Abuse then click on Information for Teens).
8. What resources can I give a teen experiencing dating violence?
• Delaware’s 24 hour Domestic Violence Hotlines are prepared to take calls from teens.
www.dvcc.delaware.gov
• School Resource Centers in Delaware have a “toolbox” with materials about teen dating
violence.
• National Teen Dating Violence Hotline www.loveisnotabuse (Liz Claiborne)
• Delaware Website for teens: www.SafeandRespectful.org
Section D - 42 - 9-2008
291

4. Homeless Students
Regulation # 901: Education of Homeless Children and Youth
This regulation provides information about the education of homeless children and youth
consistent
with the provisions of the McKinney-Vento Homeless Education Assistance Improvement Act, as
amended by the No Child Left Behind Act of 2001.
http://regulations.delaware.gov/AdminCode/title14/900/901.shtml#TopOfPage
Enrollment of Homeless Students
Homeless Students lack the required (by regulation) medical documentation of immunizations,
tuberculosis (TB) screening, a current physical and lead screening (age-dependent) for
enrollment in
school. DDOE’s School Nursing Partners newsletter (March 2003) states:
School nurses are typically assigned by districts to monitor and assure that students meet the
regulatory
requirements for school entry. Additionally, they are responsible for reducing the risk of the
entire
school to communicable disease. Because of this, they often have questions regarding how the
school
entry requirements relate to the McKinney-Vento statute.
The following are points to be considered when working with homeless students:
• McKinney-Vento requires the school to assist the family in meeting all school enrollment
requirements.
o In the case of a child without a shot record, the school needs to assist the family in
locating the record. The child should not be denied school entry during this time. In the
event the record is never found, the school can follow the Lost Records section of the
regulation if it is believed that the record was lost.
o In the case of a child missing an immunization or a required booster, the school must
assist the child in getting the vaccination. This may mean arranging for a doctor’s visit,
providing transportation, etc. It may be less interruptive to the family to address this on
the day that the child enrolls and prior to getting to the classroom; however, if this can
not be arranged immediately the child should not miss class time while waiting for an
appointment.
• Any child or staff member exhibiting signs of active communicable disease must be excluded
from participating in school activities.
o In the case of TB, a child may have multiple risk factors for TB and need to have a
Mantoux skin test; however, unless the child has symptoms of disease (ex. night sweats,
pallor, coughing, fever, etc.) he/she should not be excluded from school.
Section D - 43 - 9-2008
5. Mental Health
Division of Child Mental Health Services
Department of Services for Children, Youth and Their Families
Who is DCMHS?
The Division of Child Mental Health Services (DCMHS) is part of the Delaware Department of Services
for
Children, Youth, and Their Families (DSCYF).
Child Mental Health Services Contact Information:
Mailing Address: 1825 Faulkland Rd, Wilmington, DE 19805
292

Telephone: 302/633-2600 FAX: 302/633-5118
Email: [email protected]
Who does DCMHS serve?
The Division provides voluntary mental health and substance abuse treatment services to children up to
age 18
who have mental health or substance abuse problems and their families. They serve:
• children without health insurance;
• children with Medicaid who require services more intensive than the basic 30 hours of outpatient
treatment can provide.
What services can DCMHS provide?
• Crisis Services
• Outpatient Services
• Support Services
• Day Treatment Services
• Residential Treatment Services
• Hospital Treatment Services
These services are managed by licensed mental health professionals.

What can families expect when contacting DCMHS?
• A staff person will guide them through every step of the treatment process. There will always
be
someone to answer questions and concerns.
• The whole family is part of making the decisions about treatment.
• Information about the child and family is confidential.
• Services are voluntary; the family can choose whether or not to use them.
Contacting DCMHS:

Mental Health Emergencies
An emergency means that the child has a mental health or emotional problem which could cause
him
or her to hurt him/herself or someone else right now.
Call Crisis Services which are available 24 hours per day, 7 days per week:
• New Castle County (North of the C&D Canal) • New Castle County (South of the C&D Canal)
302-633-5128 1-800-969-HELP (4357)
• Kent & Sussex Counties
302-424-HELP (4357)
Section D - 44 - 9-2008
Non-Emergencies
If they have private insurance or Medicaid and do not need emergency services, they may call the
member
services number on the back of your insurance card.
If there is a concern about a child's mental health, but it is not urgent, have the family call their Managed
Care
Organization (MCO).
If they do not have an insurance card with a telephone number or are not sure how to get help, call:
• DCMHS Intake 302-633-2571 (Monday-Friday, 8:00 a.m. - 4:30 p.m.)
• or toll free 1-800-722-7710 (24 hours)
For non-emergencies, call the following outpatient service providers in your community.
Mental Health specialization: (MH) Substance Abuse specialization: (SA).
New Castle County
Aquila (SA): 302/999-1106
293

Children and Families First (MH) : 1-800-734-2388
Catholic Charities (MH): 302/655-9624
Delaware Guidance (MH): 302/652-3948
Jewish Family Services of Delaware (MH) : 302/478-9411
Open Door (SA): 302/731-1504
Phoenix Behavioral Health (MH & SA) : 302/736-6135
SODAT (SA) : 302/656-4044
Strategic Management Initiatives, Inc. (Crossroads) (SA): 302/652-1405
Kent County
Aquila (SA): 302/376-8610
Catholic Charities (MH): 302/674-1600
Children and Families First (MH): 1-800-734-2388
Delaware Guidance (MH): 302/678-3020
Open Door (SA): 302/678-4911
Phoenix Behavioral Health (MH & SA): 302/736-6135
People's Place (MH & SA): 302/422-8026
SODAT (SA): 302/656-4044
Sussex County
Aquila (SA): 302/856-9746
Catholic Charities (MH): 302/856-9578
Children and Families First (MH): 1-800-734-2388
Delaware Guidance (MH): 302/645-5338
People's Place (MH & SA): 302/422-8026
Phoenix Behavioral Health (MH & SA): 302/736-6135
Resource: DCMHS website, retrieved 6/6/2008 at www.kids.delaware.gov/cmhs/cmhs.shtml
Section D - 45 - 9-2008
6. Safe Arms for Babies
The following information is from the Safe Arms for Babies website:
http://www.dhss.delaware.gov/dhss/dph/chca/dphahsab01.html
Contact Information:
Toll-free 24-hour hotline: 1-800-262-9800
What is “Safe Arms for Babies”?
Safe Arms for Babies is a law that allows a parent to go to any Delaware hospital emergency department
and
leave their newborn (14 days old or younger) with any emergency department staff or volunteer. This law
provides immunity from criminal prosecution provided the baby is alive, unharmed and brought into a
hospital
emergency department.
What happens to the person surrendering the baby?
The person surrendering the baby will not be asked for identification, will not be asked who they are, will
not
have their identity revealed and will not be contacted. The employee or volunteer of the hospital will
make a
reasonable attempt to provide the person surrendering the baby with the identification number of the baby,
a
mail-back medical questionnaire [ Text of mail-back medical questionnaire ] and information about the
Safe
Arms for Babies law that includes a list of phone numbers for public and private agencies that provide
counseling and adoption services.
What happens if a baby is brought to a hospital emergency department?
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If an infant is surrendered under the law, the hospital will place a numbered identification bracelet on the
baby
as an aid in linking the person and the medical questionnaire to the baby. The baby will receive a medical
screening examination and any necessary medical care. The hospital will take temporary emergency
protective
custody of the baby and immediately notify the Division of Family Services and the State Police that a
baby has
been surrendered under the law. The Division of Family Services will request ex parte custody of the baby
from
Family Court and the State Police will submit an inquiry to the Delaware Missing Children Information
Clearinghouse. The baby will be placed with a family willing to adopt the child if parental rights are
terminated.
Can the birth parent(s) be reunited with their baby?
If a parent changes their mind and wants their baby back, they can call the Division of Family Services
hotline
at 1-800-292-9582 and say they wish to be reunited with their baby. The Division of Family Services shall
seek
to terminate parental rights unless the parent seeks reunification within 30 days of the date of surrender. It
is
important to note that the identification number given the baby at the time of surrender is an identification
aid
only and does not permit the person possessing the identification number to take custody of the baby on
demand. Once the baby has been surrendered to the hospital, the baby will not be returned by the hospital
until
the Division of Family Services and Family Court determines that the baby can be cared for safely.
Who can I call for more information?
To speak with someone directly 24-hours a day about the Safe Arms for Babies, call the toll-free 24-hour
hotline.
• Go to the Safe Arms for Babies Locations in Delaware Page
Section D - 46 - 9-2008

7. Health Counseling
Introduction
Health appraisal has very limited value unless followed by a planned program to give each
student the
care he/she needs. Parents/guardians and teachers need to be informed concerning the problems
discovered and how these problems are related to the health, growth, and welfare of the student –
a
task that may be aided by written notices or letters, but is best achieved through individual
conferences. Parents/guardians need to formulate a plan of action, and in some instances, need to
be
informed of community resources which can provide needed assistance. Some types of problems,
such
as speech defects, markedly impaired vision, or severe hearing impairment, indicate the need for
the
school to provide special or modified programs.
The term health counseling includes all of the activities of school nurses, classroom teachers and
others
directed toward helping the student to secure the professional services and special
accommodations
295

needed for his/her health condition.
One of the primary goals is to help the student assume responsibility for
improving his/her own health status.
Although health appraisal and health counseling may be considered separately, they frequently
occur
simultaneously.
Teacher-School Nurse Conferences
Purpose: · To coordinate ways to meet the health needs of the student within his/her
educational program
· To exchange information about the health of the student.
1. Schedule conferences periodically throughout the school year. The teacher’s planning period
may be a good time.
2. Prepare a list of problems or items that need discussing. Lists of health problems should not be
distributed at random.
3. For known cases of chronic conditions that may impact access to activities or may be
lifethreatening,
a conference should be scheduled at the start of the school year to discuss any
modifications of the classroom, 504 plans and/or emergency plans that may be necessary.
4. The teacher should be encouraged to keep a record of observations of students who cause
concern.
5. Extensive planning should be done for students, such as those with asthma, diabetes and
epilepsy, who might need special assistance quickly.
6. Schedule a time when the persons involved will not be interrupted.
Section D - 47 - 9-2008

Parent/Guardian-School Nurse Conferences
Purpose: · To clarify goals and actions recommended or initiated
· To report progress that may have occurred in a particular health condition
· To recommend follow-up for a problem that has been noted in the school’s
screening program.
1. The conference may be held at school or the home.
2. Prepare for the conference by reviewing health records, results of screening procedures,
conferences with appropriate school personnel and other agencies if necessary.
3. Encourage parental conversation by the use of open-ended questions that do not suggest or
limit the answer such as “How do you feel about this problem?” and “Tell me about it.”
4. Use simple, easy-to-understand language.
5. Repeat questionable statements so that the parent/guardian or nurse understands what each is
trying to tell the other.
6. Assist the family in identifying and using local and state services and resources, as needed.
Student-School Nurse Conferences
Purpose: · To provide an opportunity for the student to discuss his/her physical or
emotional health concerns
· To assist the student in making responsible decisions regarding his/her
health care
· To assist the student to learn self-care
· To obtain current up-to-date information on the health status of the
individual.
1. Meet with all new students entering the school.
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2. Accept the student’s statement as a valid report on how he/she feels at present. Students may
become “ill” under stress. Family changes can also initiate “illnesses.”
3. Try to identify factors that may be affecting the individual’s health. Use open-ended questions
that do not suggest or limit the answers.
4. Involve the student in the management of his/her health, providing him/her with possible
alternatives and avenues of assistance.
Section D - 48 - 9-2008

8. Substance Abuse
Regulation # 612: Possession, Use or Distribution of Drugs and Alcohol
This regulation addresses possession, use or distribution of drugs and alcohol in the school
setting:
http://regulations.delaware.gov/AdminCode/title14/600/612.shtml#TopOfPage
Regulation # 877: Tobacco Policy
This is regulation addresses tobacco policy in an effort to improve the health of students and
school
personnel:
http://regulations.delaware.gov/AdminCode/title14/800/877.shtml#TopOfPage
Guidelines for Students who Appear to be Under the Influence of Drugs or Alcohol
Students who become involved in substance abuse may be unstable or seriously disturbed youths
whose plight deserves treatment not censure. Note: Some medical conditions can present with
similar
symptoms and should be considered during the nursing assessment.
1. A student whose behavior and appearance seem inappropriate for that particular individual to
the
teacher, administrator, or other school personnel should be sent to the school nurse.
2. The teacher or staff member should accompany the student to the health room. If the teacher is
unable to leave his/her area, his/her observation should be written and sent to the health room.
3. The principal or school administrator should be notified of the observation made by the
teacher and
school nurse.
4. The nurse will determine through her observation and the information supplied by the teacher
if
immediate medical attention is or is not needed.
a. For emergency situations (based on vital signs and threat of danger to self):
(1) Nurse or school administrator should follow School Emergency Procedures as outlined on
the Emergency Card (see Section B).
b. For non-emergency situations:
(1) Inform the parent/guardian of student’s symptoms.
(2) Request parent/guardian to come to school.
(3) Inform parent/guardian of observations and suggest examination by family physician.
If the school has a physician on call, he/she should be requested to examine the student.
5. The procedure for treating and excluding students under the influence of drugs or alcohol are
basically the same as those used in the school district for any student showing signs of illness.
6. Keep accurate, objective and detailed records of such incidents.
Section D - 49 - 9-2008

Some Signs to Consider:
Eyes
297

• Pupils dilated or contracted
• Red and watery
• Glassy
Respiration • Rapid, shallow, labored
Pulse • Rapid, shallow, slow pulse
Change in blood pressure
Skin
• Color: pale, cyanotic, florid
• Dry and itchy
• Unusual marks
Odor • Breath
• Clothes
Behavioral Changes
• Restlessness
• Irritability
• Hyperactivity
• Mood changes
• Depression
• Lethargy
• Hyperactivity
• Change in appetite/thirst
Appendix - 1 - 04-2008

Appendix A
I. Peer Review Tool
II. Self Evaluation Tool
III. Resources for the School Nurse
Appendix - 2 - 04-2008

I. Peer Review Tool
Appendix - 3 - 04-2008
Appendix A
The Peer Review tools are used in the Brandywine School District. This review
is
intended to promote individual professional growth. Information from the
review is
confidential and not used for employee evaluation.
Peer Review
School Nurse
The purpose of this peer assessment is two-fold. Firstly, it is intended as a
tool to
ascertain appropriate Standards of Nursing Practice within our schools and to
reaffirm
our commitment to the nursing standards recognized statewide and
nationally. Secondly,
298

we hope to provide professional support for each other through objective
feedback.
It is our belief that by being given the opportunity to “step back” and look at
each of our
offices and practices from another perspective, that we can remain goalfocused, each
directing our own professional growth from year to year.
Brandywine School District, 1997
Susan Koontz, RN
Linda Lee, RN
Susan Raffauf, RN
Appendix - 4 - 04-2008
Biannual Peer Review
School Nurse
FOR: Name
School/Level
Date
REVIEW DONE IN COLLABORATION WITH:
Name
School/Level
SECTION I – ASSESSMENT To be completed by the School Nurse being
reviewed
prior to collaborative assessment.
What are your strengths and assets that contribute most to your success in
effectively
promoting the health and wellness of students and staff in your school
building?
Briefly describe a project or program that you instituted within the past two
years. Was it
effective and/or beneficial? Will you repeat the program or alter it in any
way?
What areas or personal/professional development would you consider
improvement is
indicated in order to be more greatly effective in your current position?
Identify your goal/s for the next one and two year period.
Appendix - 5 - 04-2008
SECTION 2 – CHECKLIST To be completed by peer reviewer. “Comments”
section may reflect clarification or description by either the peer reviewer or
the School
Nurse and should be followed by the initials of the author.
CHECKLIST YES NO COMMENTS
Documentation is consistent with district
recognized forms.
Daily Medication Log
PRN Medication Log
Temporary Medication Log
Documentation on health log is consistent

299

with the identified Standard SOAPIE process
The BSD computerized health log is being
utilized
Medication permission forms are complete
for all meds
Daily Medication Log reflects med bottle
labels accurately
The count of controlled drugs is documented
at least monthly
Emergency medications are labeled and
easily located
Emergency meds are all within their current
expiration dates
Medications are secured beyond double locks
when the nurse is out of her office
Substitute folder is complete according to
guideline
Substitute folder is easily located
Using the sub folder:
Emergency evacuation procedures is
current and stated.
The oxygen can be located without delay
The tank is functional and at least ½ full
Resuscitation mask with one-way valve
can be located within 30 seconds
Wheelchair can be located without delay
The student emergency cards are available
and clearly organized
The faculty emergency cards are current and
accessible.
Supplies are in labeled drawers and cabinets
Gloves are readily available and are
consistently utilized per Universal Precaution
guidelines
Upon review of #_____ student files:
Immunizations are recorded and up to
date
Hearing screen is recorded per
guidelines
Vision screen is recorded per guidelines
Orthopedic screen is recorded per
guidelines
Confidential student information is secured

Appendix - 6 - 04-2008
SECTION 3 – To be completed following a half-day observation by peer
reviewer.
What personal/professional strengths that you observed promote the overall
health and
wellness of students and staff served by the School Nurse?
What professional area/s for improvement would allow this nurse to more
effectively
serve health and wellness of students and staff?
Comments of the Peer Reviewer:
Comments of the School Nurse:
Signatures:
300

SCHOOL NURSE DATE
PEER REVIEWER DATE
Appendix - 7 - 04-2008

II. Self-Evaluation Tool
Appendix - 8 - 04-2008
Self-Evaluation Tool of School Nursing Functions
in Relation to Local Policies
Rate the following according to the scale:
Questions Relating to Functions 1 – Not a local policy 3 – Occasionally
2 – Rarely 4 – Usually
To What Extent:
Do you participate in the formulation of policies, standards and 1 2 3 4
objectives of the school health program?
Do you participate in relating the school health program to the 1 2 3 4
total school curriculum?
Do you meet with administrative and school personnel regarding 1 2 3 4
the nursing activities in the school health program?
Do you assist in planning the school health budget? 1 2 3 4
Do you use records, reports and statistical information for appraisal 1 2 3 4
and planning for the school health program?
Do you inform the administrative staff of health problems and 1 2 3 4
available resources?
Do you participate in faculty meetings? 1 2 3 4
Do you serve as resource person in the areas of health to:
Teachers 1 2 3 4
Other personnel 1 2 3 4
Students 1 2 3 4
Do you participate in curriculum planning? 1 2 3 4
Do you serve on committees concerned with:
Safety 1 2 3 4
Emotional, Mental & Social Health 1 2 3 4
Physical Health 1 2 3 4
Do you interpret health and social needs and resources to:
School groups? 1 2 3 4
Community groups? 1 2 3 4
Appendix - 9 - 04-2008
Do you interpret the school program, facilities, and policies to:
Families? 1 2 3 4
Community? 1 2 3 4
Do you promote and foster intercommunications to plan for
the well-being of pupils with:
Physicians? 1 2 3 4
Dentists? 1 2 3 4
Community Agencies? 1 2 3 4
Do you have a role in the school plan for civil defense? 1 2 3 4
301

Do you participate in studies of school nursing methods,
procedures, and service accomplishments? 1 2 3 4
Do you conduct or participate in planning and carrying out
epidemiological investigations? 1 2 3 4
Do you uncover health problems by:
Observations? 1 2 3 4
Interviews? 1 2 3 4
Analysis of records? 1 2 3 4
Do you encourage families to provide for periodic health
examinations? 1 2 3 4
Do you assist in working out a method by which findings of
health examinations are reported to the school? 1 2 3 4
Do you assume responsibility for screening procedures such as:
Vision Tuberculin
Hearing Other
Diabetes 1 2 3 4
Do you observe, evaluate and report to family physicians,
with parental approval, the pupil’s health status? 1 2 3 4
Do you have planned conferences regarding the health of
pupils with: Parents? 1 2 3 4
Teachers? 1 2 3 4
Do you visit the homes to interpret health needs of pupils? 1 2 3 4
Do you guide families toward self-help in recognition and
solution of physical, mental, social and environmental health
problems? 1 2 3 4
Appendix - 10 - 04-2008
Do you encourage families to use available health facilities? 1 2 3 4
Do you participate in the planning of a modified program for
the child with special healthcare needs? 1 2 3 4
Do you help parents and school personnel to understand and
accept children with healthcare needs? Do you interpret the
recommendations of the physician to:
Pupil? 1 2 3 4
Family? 1 2 3 4
School personnel? 1 2 3 4
Do you assist in planning curriculum for health instruction? 1 2 3 4
Do you use health services as a means of teaching:
Formal classroom setting? 1 2 3 4
Individual conference? 1 2 3 4
Do you plan with school groups to inform pupils and others
about community health projects being initiated? 1 2 3 4
Do you participate in the health education instruction upon the
request of the teacher? 1 2 3 4
Do you participate in formulating policies for the care of
pupils who become ill or injured at school? 1 2 3 4
Do you observe and report those conditions in the school
302

environment that create:
Safety hazards? 1 2 3 4
Unsanitary conditions? 1 2 3 4
Do you observe and report health and safety hazards in:
School? 1 2 3 4
Homes? 1 2 3 4
Community? 1 2 3 4
Do you assist in planning and interpreting immunization
programs to:
School personnel? 1 2 3 4
Pupils and parents? 1 2 3 4
Do you follow established policies for control of communicable
diseases? 1 2 3 4
Appendix - 11 - 04-2008
Do you belong to your professional organization?
DNA NEA-DSEA
AFT 1 2 3 4
Do you attend professional organization meetings? 1 2 3 4
Do you participate in committee work and study in your
professional organization? 1 2 3 4
Do you read professional literature regularly? 1 2 3 4
Have you read two professional books in the last six months? 1 2 3 4
Have you attended a workshop in the past year? 1 2 3 4
Have you taken any courses for college credit in the past year? 1 2 3 4
Have you earned in-service or college credits in the past year? 1 2 3 4
Have you contributed articles to professional magazines? 1 2 3 4

NIC
Nursing Intervention Classification
Definition and Activities
Copyrighted materials used with permission by Elsevier
INTRODUCTION
Quality school nursing documentation depends upon the individual school nurse accurately recording
his/her
nursing assessments, plans, interventions and client outcomes. Use of the nursing process assures that all
aspects of care are considered, addressed and written in a uniform manner. The challenge is to document
in
an efficient way that is easily comprehended by the nursing community. While medical terminology is
universally understood, it is insufficient to describe nursing aspects of client care. The need for school
nurses
to communicate in a common language has never been more vital than today as we begin to focus on
student
outcomes, build a body of research, and break down the walls of isolation between school nurse
colleagues.
To this end, standardized language amongst school nurses is essential.
303

In January 2004, Delaware School Nurse district representatives were invited to join the School Nurse
Advisory Group (SNAG). Eighteen School Nurses provided input into a pilot computer documentation
system and the development of standardized documentation. SNAG determined that identifying reasons
for
student visits to the nurse, interventions by the school nurse and outcomes from those interventions
should be
core components. Because the Nursing Intervention Classification System (NIC) had the most
comprehensive list of nursing actions, it was selected for use in Delaware. The Department of Education
(DOE) then obtained permission to use the copyrighted terminology of NIC and NOC (Nursing Outcome
Classification) in the statewide computerized program.
NIC is a unique vocabulary that describes actions performed by a nurse. Interventions can be independent
or
collaborative, direct or indirect, and individual or group oriented. NIC was initially created for hospital
use.
Use in school settings, to date, has been rare. Thus, the challenge was to narrow the over 450 NIC terms
to a
reasonable list and then to customize definitions and activities to reflect potential Delaware use.
This document contains the Delaware selected NIC terms, along with their definitions, activities and
related
readings. Where these have been altered, is noted within the text.
Terms: All NIC have been linked to Medicaid reimbursement, if appropriate. Some administrations
activities, such as seizure precautions, are not billable, but are included because of their importance in
providing comprehensive nursing services. Few terms are changed from the original NIC.
Definitions: Due to Medicaid billing requirements, some changes were made to distinguish between
a group or individual intervention or to establish a link to an injury or illness. In some cases new
definitions
and terms were created to articulate the type of care typical in Delaware schools (e.g. specific health
screenings).
Activities: These lists are neither exhaustive nor exclusive. It is likely other school nurse activities
could be added and others could be removed, based upon a particular student population.
The lists herein have removed activities that are:
� clearly hospital in nature (e.g. providing blood transfusions, monitoring electrolytes); and/or
� inappropriate for the school setting (e.g. limit visitors).
Some activities, which remain in the list:
� may require special skills (e.g. applying a cervical collar);
� are unlikely to be used in the school setting, except in special instances (e.g. obtaining a stool for
culture; monitoring skin in the perianal area);
� may require written orders from a healthcare provider (e.g. insert rectal suppository);
� should only be used AFTER an evaluation by a healthcare provider (e.g. initiate suicide precautions
should not be the first intervention for a client who threatens suicide. The first response should be an
immediate call to 911; later the school nurse may initiate suicide precautions as directed by the
discharging entity.)
Finally, some additions were needed (e.g. inform individual/family of available healthcare insurance).
The reader is cautioned that this list should not replace doctor’s orders or established protocols for an
individual client; rather, this list compiles possible nursing activities for consideration.
The introduction of NIC into Delaware documentation is an important step towards assuring quality
and standardized documentation. This document is a beginning.

Table of Contents
Nursing Intervention Classification (NIC) Codes ..........................................................................
1
304

Abuse Protection Support: Child ................................................................................................... 2
Admission Care .............................................................................................................................. 3
Airway Management ...................................................................................................................... 4
Airway Suctioning ..........................................................................................................................
5
Allergy Management ...................................................................................................................... 6
Anticipatory Guidance ................................................................................................................... 7
Artificial Airway Management .......................................................................................................
8
Aspiration Precautions ...................................................................................................................
9
Asthma Management ....................................................................................................................
10
Bleeding Reduction: Nasal ...........................................................................................................
11
Bleeding Reduction: Wound..........................................................................................................
12
Body Mechanics Promotion ......................................................................................................... 13
Bowel Management ......................................................................................................................
14
Cast Care: Maintenance .............................................................................................................. 15
Chest Physiotherapy .....................................................................................................................
16
Contact Lens Care ........................................................................................................................
17
Counseling ....................................................................................................................................
18
Diarrhea Management .................................................................................................................
19
Emergency Care ...........................................................................................................................
20
Enteral Tube Feeding ...................................................................................................................
21
Environmental Management ........................................................................................................ 22
Exercise Promotion ...................................................................................................................... 23
Feeding .........................................................................................................................................
24
Fever Treatment ........................................................................................................................... 25
First Aid ........................................................................................................................................
26
Health Care Information Exchange ............................................................................................. 27
Health Education ..........................................................................................................................
28
Health System Guidance .............................................................................................................. 29
Heat/Cold Application (injury) .................................................................................................... 30

305

Heat Exposure Treatment .............................................................................................................
31
Hemorrhage Control ....................................................................................................................
32
High-Risk Pregnancy Care .......................................................................................................... 33
Hyperglycemia Management ........................................................................................................
34
Hypoglycemia Management .........................................................................................................
35
Immunization Management ..........................................................................................................
36
Infection Protection ......................................................................................................................
37
Medication Administration ...........................................................................................................
38
Medication Management ..............................................................................................................
39
Multidisciplinary Care Conference ..............................................................................................
40
Nausea Management ....................................................................................................................
41
Neurologic Monitoring .................................................................................................................
42
Non-Nursing Intervention ............................................................................................................ 43
Nursing Asssessment, No Intervention .........................................................................................
44
Nursing Intervention .................................................................................................................... 45
Nutrition Management ................................................................................................................. 46
Nutrition, Special Diet ..................................................................................................................
47
Ostomy Care .................................................................................................................................
48
Pain Management ........................................................................................................................ 49
Positioning ................................................................................................................................... 50
Preventative Care .........................................................................................................................
51
Progressive Muscle Relaxation ....................................................................................................
52
Referral Management ...................................................................................................................
53
Respiratory Monitoring ................................................................................................................
54
Rest ...............................................................................................................................................
55
Seizure Management .................................................................................................................... 56

306

Seizure Precautions ......................................................................................................................
57
Self-Care Assistance .....................................................................................................................
58
Skin Care ......................................................................................................................................
59
Smoking Cessation Assistance ..................................................................................................... 60
Substance Use Prevention ............................................................................................................
61
Suicide Prevention ........................................................................................................................
62
Surveillance ..................................................................................................................................
63
Surveillance: Safety ......................................................................................................................
64
Surveillance: Skin .........................................................................................................................
65
Sustenance Support ......................................................................................................................
66
Telephone Consultation ................................................................................................................
67
Treatment Administration ............................................................................................................ 68
Treatment Management ................................................................................................................
69
Tube Care .....................................................................................................................................
70
Tube Care: Gastrointestinal .........................................................................................................
71
Urinary Catheterization ...............................................................................................................
72
Vital Signs Monitoring ................................................................................................................. 73
Weight Management .....................................................................................................................
74
Wound Care (ongoing) ................................................................................................................. 75
Nursing Intervention Classification Code List ..............................................................Appendix A

Nursing Intervention Classification Codes
Nursing Care: Treatment Administration TXADM
Admission Care ADMINCARE Treatment Management TXMGT
Airway Management AIRMGT Tube Care TUBECARE
Airway Suctioning AIRSUC Tube Care, Gastrointestinal TUBECAREGI
Allergy Management ALLERGY Urinary Catheterization CATH
Artificial Airway Management ARTAIR Vital Signs Monitoring VS
Aspiration Precautions ASPIR Wound Care (Ongoing) WOUNDON
Asthma Management ASTHMA
Bleeding Reduction: Nasal NOSEBL Counseling:
Bleeding Reduction: Wound BLEED Abuse Protection Support: Child ABUSE
Bowel Management BWL Counseling (individual) COUNSEL
Cast Care: Maintenance CAST Counseling (group) COUNSELG

307

Chest Physiotherapy CHEST
Contact Lens Care EYECL Health Education:
Diarrhea Management DIARR Anticipatory Guidance (individual) AGUIDE
Emergency Care (illness) ERILL Anticipatory Guidance (group) AGUIDEG
Emergency Care (injury) ERINJ Body Mechanics Promotion (individual) BODY
Enteral Tube Feeding TUBEFEED Body Mechanics Promotion (group) BODYG
Feeding FEED Exercise Promotion (individual) EXER
Fever Treatment FVR Exercise Promotion (group) EXERG
First Aid WOUNDFA Health Education (individual) HLTHED
Health Care Information Exchange (illness) INFOILL Health Education (group) HLTHEDG
Health Care Information Exchange (injury) INFOINJ Smoking Cessation Assistance (individual) SMOKE
Heat/Cold Application (injury) HTCLD Smoking Cessation Assistance (group) SMOKEG
Heat Exposure Treatment HEATX Substance Use Prevention (individual) SUBAB
Hemorrhage Control HMRR Substance Use Prevention (group) SUBABG
High-Risk Pregnancy Care PREG Weight Management WGTMGT
Hyperglycemia Management HYPERG
Hypoglycemia Management HYPOG Health Promotion/Protection:
Medication Administration MEDADM Environmental Management ENVMGT
Medication Management MEDMGT Health System Guidance HGUIDE
Multidisciplinary Care Conference (illness) CONFILL Immunization Management IZMGT
Multidisciplinary Care Conference (injury) CONFINJ Infection Protection INFPRO
Nausea Management NAUSEA Preventative Care PREVCAR
Neurologic Monitoring NEURO Progressive Muscle Relaxation MURELX
Non-Nursing Intervention NONNURSE Seizure Precautions SZRPRE
Nursing Assessment, No Intervention NASS Suicide Prevention PRESUI
Nursing Intervention NURSE Surveillance: Safety SAFE
Nutrition Management NUTMGT Sustenance Support SUST
Nutrition, Special Diet SPDIET
Ostomy Care OSTO
Pain Management PAIN
Positioning POSI
Referral Management REFMGT
Respiratory Monitoring RESP
Rest REST
Seizure Management SZR
Self-Care Assistance, Nursing SELFNUR
Self-Care Assistance, Non-Nursing SELFNON
Skin Care SKIN
Surveillance SURV
Surveillance: Skin SKINSRV
Telephone Consultation TC

NIC Definition & Activities Page 1 9-2006

Abuse Protection Support: Child (ABUSE)
Definition1: Identification of high-risk, dependent child relationships and actions to prevent possible
or
further infliction of physical, sexual or emotional harm or neglect of basic necessities of life.
Activities:
Report suspected abuse or neglect to proper authorities
Identify mothers who have a history of late (4 months or later) or no prenatal care
Identify parents who have had another child removed from the home or have placed previous children with relatives for extended periods
Identify parents who have a history of substance abuse, depression, or major psychiatric illness
Identify parents who demonstrate an increased need for parent education (e.g., parents with learning problems, parents who verbalize feelings of
inadequacy, parents of a first child, teen parents)
Identify parents with a history of domestic violence or a mother who has a history of numerous “accidental” injuries
Identify parents with a history of unhappy childhoods associated with abuse, rejection, excessive criticism, or feelings of being worthless and
unloved
Identify crisis situations that may trigger abuse (e.g., poverty, unemployment, divorce, homelessness, and domestic violence)

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Determine whether the family has an intact social support network to assist with family problems, respite child care, and crisis child care
Identify infants/children with high-care needs (e.g., prematurity, low birth weight, colic, feeding intolerances, major health problems in the first
year of
life, developmental disabilities, hyperactivity, and attention deficit disorders)
Identify caretaker explanations of child’s injuries that are improbable or inconsistent, allege self-injury, blame other children, or demonstrate a
delay in
seeking treatment
Determine whether a child demonstrates signs of physical abuse, including numerous injuries in various stages of healing; unexplained bruises &
welts;
unexplained pattern, immersion, & friction burns; facial, spiral, shaft, or multiple fractures; unexplained facial lacerations & abrasions; human
bite
marks; intracranial, subdural, intraventricular, & intraoccular hemorrhaging; whiplash shaken infant syndrome; & diseases that are resistant to
treatment and/or have changing signs & symptoms
Determine whether the child demonstrates signs of neglect, including poor or inconsistent growth patterns, failure to thrive, wasting of
subcutaneous
tissue, consistent hunger, poor hygiene, constant fatigue and listlessness, bald patches on scalp or other skin afflictions, apathy, unyielding body
posture, and inappropriate dress for weather conditions
Determine whether the child demonstrates signs of sexual abuse, including difficulty walking or sitting; torn, stained, or bloody underclothing;
reddened
or traumatized genitals; vaginal or anal lacerations; recurrent urinary tract infections; poor sphincter tone; acquired sexually transmitted diseases;
pregnancy; promiscuous behavior or prostitution; a history of running away, sudden massive weight loss or weight gain, aggression against self,
or
dramatic behavioral or health changes of undetermined etiology
Determine whether the child demonstrates signs of emotional abuse, including lags in physical development, habit disorders, conduct learning
disorders,
neurotic traits/psychoneurotic reactions, behavioral extremes, cognitive developmental lags, and attempted suicide
Monitor child for extreme compliance, such as passive submission to invasive procedures
Monitor child for role reversal, such as comforting the parent, or overactive or aggressive behavior
Listen to pregnant woman’s feelings about pregnancy and expectations about the unborn child
Monitor new parents’ reactions to their infant, observing for feelings of disgust, fear, or disappointment in gender
Monitor for a parent who holds newborn at arm’s length, handles newborn awkwardly, asks for excessive assistance, & verbalizes or
demonstrates
discomfort in caring for the child
Monitor for repeated visits to clinics, emergency rooms, or physicians’ offices for minor problems
Determine parent’s knowledge of infant/child basic care needs and provide appropriate child care information as indicated
Instruct parents on problem solving, decision making, and childrearing & parenting skills, or refer parents to programs where these skills can be
learned
Help families identify coping strategies for stressful situations
Provide parents with information on how to cope with protracted infant crying, emphasizing that they should not shake the baby
Provide the parents with noncorporal punishment methods for disciplining children
Provide pregnant women and their families with information on the effects of smoking, poor nutrition, & substance abuse on the baby’s and their
health
Engage parents and child in attachment-building exercises
Provide parents and their adolescents with information on decision making & communication skills & refer to youth services counseling, as
appropriate
Provide older children with concrete information on how to provide for the basic care needs of their younger siblings
Provide children with positive affirmations of their worth, nurturing care, therapeutic communication, and developmental stimulation
Refer families to human services and counseling professionals, as needed
Provide parents with community resource information that includes addresses and phone numbers of agencies that provide respite care,
emergency child
care, housing assistance, substance abuse treatment, sliding-fee counseling services, food pantries, clothing distribution centers, health care,
human
services, hot lines, and domestic abuse shelters
Refer a parent who is being battered and at-risk children to a domestic violence shelter
Refer parents to Parents Anonymous for group support, as appropriate
Background Readings:
Campbell, J., & Humphreys, J. (1993). Nursing care of survivors of family violence (2nd ed.). St. Louis: Mosby.
Campbell, J., & Humphreys, J. (1984). Nursing care of victims of family violence. Reston, VA: Reston Publishing.
Cicchetti, D., & Carlson, V. (Eds.). (1990). Child maltreatment: Theory and research on the causes and consequences of child abuse and neglect. New York:
Cambridge
University Press.
Cowen, P.S. (1994). Child abuse–What’s nursing’s role? In J.C. McCloskey & H.K. Grace (Eds.), Current issues in nursing (4th ed.) (pp. 731-741). St. Louis: Mosby.
Cowen, P.S., & Van Hoozer, H. (1993). Family violence computer assisted instruction programs. Chapel Hill: Health Sciences Consortium.
Dove, A., & Kobryn, M. (1991). Computer detection of child abuse. Nursing Standard, 6(10), 38-39.
Dykes, L.J. (1986). The whiplash shaken infant syndrome: What has been learned? Child Abuse & Neglect, 10, 211-221.
Rosenberg, D.A. (1987). Web of deceit: A literature review of Munchausen syndrome by proxy. Child Abuse & Neglect, 11(4), 547-563.
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definition; NIC definition reads identification of high-risk dependent relationships and actions to prevent further infliction of physical or emotional harm.

NIC Definition & Activities Page 2 9-2006

Admission Care (ADMINCARE)
Definition1: Facilitating entry of a student into the school setting and identifying/addressing
309

his/her healthcare needs.
Activities:
Introduce yourself and your role in providing care
Orient patient/family/guardian to expectations of care
Provide appropriate privacy for the patient/family/guardian
Orient patient/family/guardian to immediate environment
Orient patient/family/guardian to agency facilities
Obtain admission history including information on past medical illnesses, medications, and
allergies
Inform parent/family/guardian of school entry requirements; i.e., physical, immunizations, etc.
Perform admission risk assessment, as appropriate (e.g., TB screening, skin assessment)
Obtain healthcare provider information
Establish individualized healthcare plan, as appropriate
Document pertinent information
Maintain confidentiality of patient data
Implement safety precautions, as appropriate
Obtain physician’s orders for patient care, as appropriate
Determine healthcare needs for school setting
Background Reading:
Perry, A., & Potter, P.A. (2002). Clinical nursing skill and techniques (5th ed.). St. Louis: Mosby.
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definition; NIC definition reads facilitating entry of a patient into a health care facility

NIC Definition & Activities Page 3 9-2006

Airway Management (AIRMGT)
Definition: Facilitation of patency of air passages.
Activities:
Open the airway, using the chin lift or jaw thrust technique, as appropriate
Position patient to maximize ventilation potential
Identify patient requiring actual/potential airway insertion
Insert oral or nasopharyngeal airway, as appropriate
Perform chest physical therapy, as appropriate
Remove secretions by encouraging coughing or by suctioning
Encourage slow, deep breathing; turning; and coughing
Use fun techniques to encourage deep breathing for children (e.g., blow bubbles with bubble
blower;
blow on pinwheel, whistle, harmonica, balloons, party blowers; have blowing contest using
pingpong
balls, feathers)
Instruct how to cough effectively
Assist with incentive spirometer, as appropriate
Auscultate breath sounds, noting areas of decreased or absent ventilation and presence of
adventitious
sounds
Perform endotracheal or nasotracheal suctioning, as appropriate
Administer bronchodilators, as appropriate
Teach patient how to use prescribed inhalers, as appropriate
Administer aerosol treatments, as appropriate
Administer ultrasonic nebulizer treatments, as appropriate
310

Administer humidified air or oxygen, as appropriate
Regulate fluid intake to optimize fluid balance
Position to alleviate dyspnea
Monitor respiratory and oxygenation status, as appropriate
Background Readings:
American Association of Critical Care Nurses. (1998). Core curriculum for critical care nursing (5th ed.).
Philadelphia: W.B. Saunders
Perry, A.G., & Potter, P.A. (2002). Clinical nursing skills and techniques (5th ed.). St. Louis: Mosby.
Racht, E.M. (2002). 10 pitfalls in airway management: how to avoid common airway management
complications. JEMS: Journal of Emergency Medical Services, 27(3), 28-30, 32-4, 36-8.

NIC Definition & Activities Page 4 9-2006

Airway Suctioning (AIRSUC)
Definition: Removal of airway secretions by inserting a suction catheter into the patient’s
oral
airway and/or trachea.
Activities:
Determine the need for oral and/or tracheal suctioning
Auscultate breath sounds before and after suctioning
Inform the patient and family about suctioning
Aspirate the nasopharynx with a bulb syringe or suction device, as appropriate
Provide sedation, as appropriate
Use universal precautions: gloves, goggles, and mask, as appropriate
Insert a nasal airway to facilitate nasotracheal suctioning, as appropriate
Instruct the patient to take several deep breaths before nasotracheal suctioning and use supplemental
oxygen,
as appropriate
Hyperoxygenate with 100% oxygen, using the ventilator or manual resuscitation bag
Hyperinflate at 1 to 1.5 times the preset tidal volume using the mechanical ventilator, as appropriate
Use sterile disposable equipment for each tracheal suction procedure
Select a suction catheter that is one half the internal diameter of the endotracheal tube, tracheostomy tube,
or
patient’s airway
Instruct the patient to take slow, deep breaths during insertion of the suction catheter via the nasotracheal
route
Leave the patient connected to the ventilator during suctioning, if a closed tracheal suction system or an
oxygen insufflation device adaptor is being used
Use the lowest amount of wall suction necessary to remove secretions (e.g., 80 to 100 mm Hg for adults)
Monitor patient’s oxygen status (SaO2 and SvO2 levels) and hemodynamic status (MAP level and cardiac
rhythms) immediately before, during, and after suctioning
Base the duration of each tracheal suction pass on the necessity to remove secretions and the patient’s
response
to suctioning
Hyperinflate and hyperoxygenate between each tracheal suction pass and after the final suction pass
Suction the oropharynx after completion of tracheal suctioning
Clean area around tracheal stoma after completion of tracheal suctioning, as appropriate
Stop tracheal suctioning and provide supplemental oxygen if patient experiences bradycardia, an increase
in
ventricular ectopy, and/or desaturation
Vary suctioning techniques, based on the clinical response of the patient
Note type and amount of secretions obtained
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Send secretions for culture and sensitivity tests, as appropriate
Instruct the patient and/or family how to suction the airway, as appropriate

Background Readings:
Barnes, C., & Kirchhoff, K.T. (1986). Minimizing hypoxemia due to endotracheal suctioning: A review of the
literature.
Heart & Lung, 15, 164-176.
Craven, R. F., & Hirnle, C. J. (2000) Fundamentals of nursing: Human health and function (3rd ed.) (pp. 825-827).
Philadelphia: Lippincott.
Nelson, D.M. (1992). Interventions related to respiratory care. In G.M. Bulechek & J.C. McCloskey (Eds.),
Symposium on Nursing Interventions. Nursing Clinics of North America, 27(2), 301-324.
Stone, K., & Turner, B. (1988). Endotracheal suctioning. Annual Review of Nursing Research, 7, 27-49.
Stone, K.S., Preusser, B.A., Groch, K.F., Karl, J.I., & Gronyon, D.S. (1991). The effect of lung hyperinflation and
endotracheal suctioning on cardiopulmonary hemodynamics. Nursing Research, 40(2), 76-79.
Titler, M.G., & Jones, G. (1992). Airway management. In G.M. Bulechek & J.C. McCloskey (Eds.), Nursing
interventions: Essential nursing treatments (2nd ed.) (pp. 512-530). Philadelphia: W.B. Saunders.

NIC Definition & Activities Page 5 9-2006

Allergy Management (ALLERGY)
Definition: Identification, treatment, and prevention of allergic responses to food,
medications,
insect bites, contrast material, blood, and other substances.
Activities:
Identify known allergies (e.g., medication, food, insect, environmental) and usual reaction
Notify caregivers and health care providers of known allergies
Document all allergies in clinical record, according to protocol
Monitor patient for allergic reactions to new medications, formulas, foods, latex, and/or test dyes
Monitor the patient following exposures to agents known to cause allergic responses for signs of
generalized flush, angioedema, urticaria, paroxysmal coughing, severe anxiety, dyspnea,
wheezing, orthopnea, vomiting, cyanosis, or shock
Keep patient under observation for 30 minutes following administration of an agent known to be
capable of inducing an allergic response
Instruct the patient with medication allergies to question all new prescriptions regarding potential
for
allergic reactions
Encourage patient to wear a medical alert tab, as appropriate
Identify immediately the level of threat an allergic reaction presents to patient’s health status
Monitor for reoccurrence of anaphylaxis within 24 hours
Provide life-saving measures during anaphylactic shock or severe reactions
Provide medication to reduce or minimize an allergic response
Watch for allergic responses during immunizations
Instruct patient/parent to avoid substances that cause allergic reactions, as appropriate
Instruct patient/parent in how to treat rashes, vomiting, diarrhea, or respiratory problems
associated
with exposure to allergy-producing substance
Instruct patient to avoid further use of substances causing allergic responses
Discuss methods to control environmental allergens (e.g., dust, mold, and pollen)
Instruct patient and caregiver(s) on how to avoid situations that put the patient at risk and how to
respond if an anaphylactic reaction should occur
Instruct patient and caregiver on use of epinephrine pen
312

Background Readings:
Hendry, C., & Farley, A.H. (2001). Understanding allergies and their treatment. Nursing Standard, 15(35),
4753.
Hoole, A., Pickard, C., Ouimette, R., Lohr, J., & Greenberg, R. (1995). Patient care guidelines for nurse
practitioners (4th ed.). Philadelphia: J.B. Lippincott.
Lemone, P., & Burke, K. (1996). Medical surgical nursing: Critical thinking in client care. Menlo Park,
CA:
Addison-Wesley.
Trzcinski, K.M. (1993). Update on common allergic diseases. Pediatric Nursing, 19(4), 410-415.

NIC Definition & Activities Page 6 9-2006

Anticipatory Guidance (AGUIDE and AGUIDEG)
Definition1: Preparation of patient or group of patients for an anticipated developmental
and/or situational crisis.
Anticipatory Guidance (individual) AGUIDE
Anticipatory Guidance (group) AGUIDEG
Activities:
Assist the patient to identify possible upcoming, developmental, and/or situational crisis and the
effects the crisis may have on personal and family life
Instruct about normal development and behavior, as appropriate
Provide information on realistic expectations related to the patient’s behavior
Determine the patient’s usual methods of problem solving
Assist the patient to decide how the problem will be solved
Assist the patient to decide who will solve the problem
Use case examples to enhance the patient’s problem-solving skills, as appropriate
Assist the patient to identify available resources and options for course of action, as appropriate
Rehearse techniques needed to cope with upcoming developmental milestone or situational crisis
with the patient, as appropriate
Assist the patient to adapt to anticipated role changes
Provide a ready reference for the patient (e.g., educational materials/pamphlets), as appropriate
Suggest books/literature for the patient to read, as appropriate
Refer the patient to community agencies, as appropriate
Schedule visits at strategic developmental/situational points
Schedule extra visits for patient with concerns or difficulties
Schedule follow-up phone calls to evaluate success or reinforcement needs
Provide the patient with a phone number to call for assistance, if necessary
Include the family/significant others, as appropriate
Background Readings:
Craven, R. F., & Hirnle, C.J. (2000). Fundamentals of nursing: Human health and function (3rd ed.) (pp.
12691270). Philadelphia: Lippincott.
Denehy, J.A. (1990). Anticipatory guidance. In M.J. Craft & J.A. Denehy (Eds.), Nursing interventions
for
infants and children (pp. 53-68). Philadelphia: W.B. Saunders.
Rakel, B.A. (1992). Interventions related to patient teaching. In G.M. Bulechek & J.C. McCloskey (Eds.),
Symposium on Nursing Interventions. Nursing Clinics of North America, 27(2), 397-424.
Schulman, J.L., & Hanley, K.K. (1987). Anticipatory guidance: An idea whose time has come. Baltimore:
Williams & Wilkins.
313

Smith, C.E. (1987). Using the teaching process to determine what to teach and how to evaluate learning.
In
C.E. Smith (Ed.), Patient education: Nurses in partnership with other health professionals (pp. 61-95).
Philadelphia: W.B. Saunders.
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definition differentiates between individual or group intervention.

NIC Definition & Activities Page 7 9-2006

Artificial Airway Management (ARTAIR)
Definition: Maintenance of endotrachial and tracheostomy tubes and prevention of
complications associated with their use.
Activities:
Provide an oropharyngeal airway or bite block to prevent biting on the endotracheal tube, as appropriate
Provide 100% humidification of inspired gas/air
Provide adequate systemic hydration via oral or intravenous fluid administration
Inflate endotracheal/tracheostoma cuff using minimal occlusive volume technique or minimal leak technique
Maintain inflation of the endotracheal/tracheostoma cuff at 15 to 20mm Hg during mechanical ventilation and
during and
after feeding
Suction the oropharynx and secretions from the top of the tube cuff before deflating cuff
Monitor cuff pressures every 4 to 8 hours during expiration using a three-way stopcock, calibrated syringe, and
mercury
manometer
Check cuff pressure immediately after delivery of any general anesthesia
Change endotracheal tapes/ties every 24 hours, inspect the skin and oral mucosa, and move ET tube to the other side
of
the mouth
Loosen commercial endotracheal tube holders at least once a day, and provide skin care
Auscultate for presence of lung sounds bilaterally after insertion and after changing endotracheal/tracheostomy ties
Note the centimeter reference marking on endotracheal tube to monitor for possible displacement
Assist with chest x-ray examination, as needed, to monitor position of tube
Minimize leverage and traction on the artificial airway by suspending ventilator tubing from overhead supports,
using
flexible catheter mounts and swivels, and supporting tubes during turning, suctioning, and ventilator disconnection
and reconnection
Monitor for presence of crackles and rhonchi over large airways
Monitor for decrease in exhaled volume and increase in inspiratory pressure in patients receiving mechanical
ventilation
Institute endotracheal suctioning, as appropriate
Institute measures to prevent spontaneous decannulation: secure artificial airway with tape/ties; administer sedation
and
muscle-paralyzing agent, as appropriate; and use arm restraints, as appropriate
Provide additional intubation equipment and ambu bag in a readily available location
Provide trachea care every 4 to 8 hours as appropriate: clean the inner cannula, clean and dry the area around the
stoma,
and change tracheostomy ties
Inspect skin around tracheal stoma for drainage, redness, and irritation
Maintain sterile technique when suctioning and providing tracheostomy care
Shield the tracheostomy from water
Provide mouth care and suction oropharynx, as appropriate
Tape the tracheostomyobturator to head of bed
Tape a second tracheostomy tube (same type and size) and forceps to head of bed
Institute chest physiotherapy, as appropriate
Ensure that endotracheal/tracheostomy cuff is inflated during feedings, as appropriate
Elevate head of the bed or assist patient to a sitting position in a chair during feedings, as appropriate
Add food coloring to enteral feedings, as appropriate

314

Background Readings:
Boggs, R.L., & Woolridge-Kim, M. (1993). AACN procedural manual for critical care (3rd ed). Philadelphia: W.B.
Saunders.
Craven, R.F., & Hirnle, C. J. (2000) Fundamentals of Nursing: Human Health and Function (3rd ed.) (pp. 819-824).
Philadelphia: Lippincott
Goodnough, S.K.C. (1988). Reducing tracheal injury and aspiration. Dimensions of Critical Care Nursing, 7, 324331.
McHugh, J.M. (1985). Airway management. In S. Millar, L.K., Sampson, & M. Soukup (Eds.), AACN Procedural
Manual for Critical Care (pp. 203-239). Philadelphia: W.B. Saunders.
Nelson, D.M. (1992). Interventions related to respiratory care. In G.M. Bulechek & J.C. McCloskey (Eds.),
Symposium
on Nursing Interventions. Nursing Clinics of North America, 27(2), 301-324.
Titler, M.G., & Jones, G. (1992). Airway management. In G.M. Bulechek & J.C. McCloskey (Eds.), Nursing
Interventions: Essential Nursing Treatments (2nd ed.) (pp. 512-530). Philadelphia: W.B. Saunders.

NIC Definition & Activities Page 8 9-2006

Aspiration Precautions (ASPIR)
Definition: Prevention or minimization of risk factors in the patient at risk for aspiration.
Activities:
Monitor level of consciousness, cough reflex, gag reflex, and swallowing ability
Monitor pulmonary status
Maintain an airway
Position upright 90 degrees or as far as possible
Keep tracheal cuff inflated
Keep suction setup available
Feed in small amounts
Check NG or gastrostomy tube placement before feeding
Check NG or gastrostomy tube residual before feeding
Avoid feeding, if residuals are high
Place “dye” in NG feeding tube
Avoid liquids or use thickening agent
Offer foods or liquids that can be formed into a bolus before swallowing
Cut food into small pieces
Request medication in elixir form
Break or crush pills before administration
Keep head of bed elevated 30 to 45 minutes after feeding
Suggest speech pathology consult, as appropriate
Suggest barium cookie swallow or video fluoroscopy, as appropriate
Background Readings:
Ackerman, L.L. (1992). Interventions related to neurological care. In G.M. Bulechek & J.C. McCloskey
(Eds.), Symposium on Nursing Interventions. Nursing Clinics of North America, 27(2), 325-346.
American Nurses’ Association Council in Medical-Surgical Nursing Practice & American Association of
Neuroscience Nurses. (1985). Neuroscience nursing practice: Process and outcome for selected
diagnoses.
Kansas City, MO: American Nurses Association.
Maas, M.L., Buckwalter, K.C., Hardy, M.D., Reimer, T.T., Titler, M.G., & Specht, J.P. (2001) Nursing
Care
of Older Adults: Diagnoses, Outcomes, and Interventions (pp. 167-168). St. Louis: Mosby.
Sands, J.A. (1991). Incidence of pulmonary aspiration in intubated patients receiving enteral nutrition
through
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wide- and narrow-bore nasogastric feeding tubes. Heart & Lung, 20(1), 75-80.
Schwartz-Cowley, R., & Gruen, A.K. (1988). Swallowing dysfunction in patients with altered mobility. In
P.H. Mitchell, L.C. Hodges, M. Muwaswes, et al. (Eds.), AANN’s Neuroscience Nursing (pp. 345-357).
Norwalk, CT: Appleton & Lange.
Taylor, T. (1982). A comparison of two methods of nasogastric tube feedings. Journal of Neurosurgical
Nursing, 14(1), 49-55.

NIC Definition & Activities Page 9 9-2006

Asthma Management (ASTHMA)
Definition: Identification, treatment and prevention of reactions to
inflammation/constriction in
the airway passages.
Activities:
Determine baseline respiratory status to use as a comparison point
Document baseline measurements in clinical record
Compare current status with previous status to detect changes in respiratory status
Monitor peak expiratory flow rate (PERF), as appropriate
Educate patient about the use of the PERF meter at home
Monitor for asthmatic reactions
Determine client/family understanding of disease and management
Instruct client/family on anti-inflammatory and bronchodilator medications and their appropriate use
Teach proper techniques for using medication and equipment (e.g., inhaler, nebulizer, peak flow meter)
Determine compliance with prescribed treatments
Encourage verbalization of feelings about diagnosis, treatment, and impact on lifestyle
Identify known triggers and usual reaction
Teach client to identify and avoid triggers as possible
Establish a written plan with the client for managing exacerbations
Assist in the recognition of signs/symptoms of impending asthmatic reaction and implementation of
appropriate response measures
Monitor rate, rhythm, depth, and effort of respiration
Note onset, characteristics, and duration of cough
Observe chest movement, including symmetry, use of accessory muscles, and supraclavicular and
intercostal
muscle retractions
Auscultate breath sounds, noting areas of decreased/absent ventilation and adventitious sounds
Administer medication as appropriate and/or per policy and procedural guidelines
Auscultate lung sounds after treatment to determine results
Offer warm fluids to drink, as appropriate
Coach in breathing/relaxation techniques
Use a calm, reassuring approach during asthma attack
Inform client/family about the policy & procedures for carrying & administration of asthma medications
at
school
Inform parent/guardian when child has needed/used PRN medication in school, as appropriate
Refer for medical assessment, as appropriate
Establish a regular schedule of follow-up care
Instruct and monitor pertinent school staff in emergency procedures
Prescribe and/or renew asthma medications, as appropriate
Background Readings:
American Academy of Allergy, Asthma and Immunology. (1999). Pediatric Asthma: Promoting Best Practice. Guide for
Managing
Asthma in Children. Milwaukee, WI: Author.

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National Asthma Education and Prevention Program. Second Expert Panel. (1997). Guidelines for Diagnosis and Management of
Asthma. NIH Publication No. 97-4051.
Silkworth, C.K. (1993). IHP: Asthma. In M.B. Haas, M.J.V. Gerber, W.R. Miller, K.M. Kalb, C.K. Silkworth, R.E. Leuhr, &
S.I.S.
Will. (Eds.), The School Nurse’s Source Book of Individualized Healthcare Plans—Volume 1. (pp. 133-150). North Branch, MN:
Sunrise River Press.
Szilagyi, P. & Kemper, K. (1999). Management of chronic childhood asthma in the primary care office. Pediatric Annuals, 28(1),
4352.
University of Michigan Health System. (2000). Asthma: Guidelines for clinical care. Available online: http://www.cme.med.
umich.edu/ pdf/guideline/asthma.pdf
Yoos, H.L., & McMullen, A. (1999). Symptom monitoring in childhood asthma: How to use a peak flow meter. Pediatric Annals,
28(1), 31-39.

NIC Definition & Activities Page 10 9-2006

Bleeding Reduction: Nasal (NOSEBL)
Definition: Limitation of the amount of blood loss from the nasal cavity.
Activities:
Apply manual pressure over the bleeding or the potential bleeding area
Identify the cause of the bleeding
Monitor the amount and nature of blood loss
Monitor the amount of bleeding into the oropharynx
Apply ice pack to affected area
Place packing in nasal cavity, if appropriate
Instruct the patient on activity restrictions, if appropriate
Promote stress reduction
Provide pain relief/comfort measures
Maintain a patent airway
Instruct patient to avoid traumatizing nares (e.g., avoid scratching or touching nose)
Assist patient with oral care, as appropriate
Instruct the patient and/or family on signs of bleeding and appropriate actions (e.g., notify the
nurse),
should further bleeding occur
Background Readings:
Cullen, L.M. (1992). Interventions related to circulatory care. In G.M. Bulechek & J.C. McCloskey
(Eds.),
Symposium on Nursing Interventions. Nursing Clinics of North America, 27(2), 445-476.
Jennings, B. (1991). The hematologic system. In J. Alspach (Ed.), AACN’s core curriculum for critical
care
nursing (4th ed.) (pp. 675-747). Philadelphia: W.B. Saunders.
Johanson, B.C., Wells, S.J., Hoffmeister, D., & Dungca, C.U. (1988). Standards for critical care (3rd ed.).
St.
Louis: Mosby.
Kitt, S., & Karser, J. (1990). Emergency nursing: A physiological and clinical perspective. Philadelphia:
W.B.
Saunders.
Thompson, J.M., McFarland, G.K., Hirsch, J.E., & Tucker, S.M. (1998). Mosby’s clinical nursing (4th
ed.). St.
Louis: Mosby.

NIC Definition & Activities Page 11 9-2006

Bleeding Reduction: Wound (BLEED)
317

Definition: Limitation of the blood loss from a wound that may be a result of trauma,
incisions,
or placement of a tube or catheter.
Activities:
Identify the cause of the bleeding
Monitor the patient closely for hemorrhage
Monitor the amount and nature of blood loss
Monitor trends in blood pressure and hemodynamic parameters, if available (e.g., central venous
pressure and pulmonary capillary/artery wedge pressure)
Monitor fluid status, including intake and output, as appropriate
Instruct the patient and/or family on signs of bleeding and appropriate actions (e.g., notify the
nurse),
should further bleeding occur
Instruct the patient on activity restrictions, if appropriate
Instruct patient and family on severity of blood loss and appropriate actions being performed
Perform proper precautions in handling blood products or bloody secretions
Apply direct pressure or pressure dressing, if appropriate
Background Readings:
Cullen, L.M. (1992). Interventions related to circulatory care. In G.M. Bulechek & J.C. McCloskey
(Eds.),
Symposium on Nursing Interventions. Nursing Clinics of North America, 27(2), 445-476.
Jennings, B. (1991). The hematologic system. In J. Alspach (Ed.), AACN’s core curriculum for critical
care
nursing (4th ed.) (pp. 675-747). Philadelphia: W.B. Saunders.
Johanson, B.C., Wells, S.J., Hoffmeister, D., & Dungca, C.U. (1988). Standards for critical care (3rd ed.).
St.
Louis: Mosby.
Thompson, J.M., McFarland, G.K., Hirsch, J.E., & Tucker, S.M. (1998). Mosby’s clinical nursing (4th
ed.). St.
Louis: Mosby.

NIC Definition & Activities Page 12 9-2006

Body Mechanics Promotion (BODY and BODYG)
Definition1: Facilitating a patient or a group of patients in the use of posture and movement
in
daily activities to prevent fatigue and musculoskeletal strain or injury.
Body Mechanics Promotion (individual) BODY
Body Mechanics Promotion (group) BODYG
Activities:
Determine patient’s commitment to learning and using correct posture
Collaborate with physical/occupational therapy in developing a body mechanics promotion plan,
as
indicated
Determine patient’s understanding of body mechanics and exercises (e.g., return demonstration
of
correct techniques while performing activities/exercises)
Instruct patient on structure and function of spine and optimal posture for moving and using the
body
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Instruct patient about need for correct posture to prevent fatigue, strain, or injury
Instruct patient how to use posture and body mechanics to prevent injury while performing any
physical activities
Determine patient awareness of own musculoskeletal abnormalities and the potential effects of
posture and muscle tissue
Instruct to use a firm mattress/chair or pillow, if appropriate
Instruct to avoid sleeping prone
Assist to demonstrate appropriate sleeping positions
Assist to avoid sitting in the same position for prolonged periods
Demonstrate how to shift weight from one foot to another while standing
Instruct patient to move feet first and then body when turning to walk from a standing position
Assist patient/family to identify appropriate posture exercises
Assist patient to select warm-up activities before beginning exercise or work not done routinely
Assist patient to perform flexion exercises to facilitate back mobility, as indicated
Instruct patient/family regarding frequency and number of repetitions for each exercise
Monitor improvement in patient’s posture/body mechanics
Provide information about possible positional causes of muscle or joint pain
Background Readings:
Craven, R.F., & Hirnle, C.J. (2000) Fundamentals of nursing: Human health and function (3rd ed.). (pp.
738739). Philadelphia: Lippincott.
Glick, O.J. (1992). Interventions related to activity and movement. In G.M. Bulechek & J.C. McCloskey
(Eds.), Symposium on Nursing Interventions. Nursing Clinics of North America, 27(2), 541-568.
Lewis, C.B. (1989). Improving mobility in older persons. Rockville, MD: Aspen.
Sheahan, S. (1982). Assessment of low back pain. Nurse Practitioner, 7, 15-23.
Sweezey, S. (1988). Low back pain. Geriatrics, 43(2), 39-44.
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definition differentiates between individual or group intervention.

NIC Definition & Activities Page 13 9-2006

Bowel Management (BWL)
Definition: Establishment and maintenance of a regular pattern of bowel elimination.
Activities:
Note date of last bowel movement
Monitor bowel movements including frequency, consistency, shape, volume, and color, as
appropriate
Monitor bowel sounds
Report an increase in frequency of and/or high-pitched bowel sounds
Report diminished bowel sounds
Monitor for signs and symptoms of diarrhea, constipation, and impaction
Evaluate for fecal incontinence as necessary
Note preexistent bowel problems, bowel routine, and use of laxatives
Teach patient about specific foods that assist in promoting bowel regularity
Instruct patient/family members to record color, volume, frequency, and consistency of stools
Initiate a bowel training program, as appropriate
Encourage decreased gas-forming food intake, as appropriate
Instruct patient on foods high in fiber, as appropriate
Give warm liquids after meals, as appropriate
Evaluate medication profile for gastrointestinal side effects
319

Refrain from doing rectal/vaginal examination if medical condition warrants
Background Readings:
Craft, M.J., & Denehy, J.A. (Eds.). (1990). Nursing interventions for infants and children. Philadelphia:
W.B.
Saunders.
Craven, R.F., & Hirnle, C.J. (2000) Fundamentals of nursing: Human health and function (3rd ed.) (pp.
10771114). Philadelphia: Lippincott.
Goetz, L.L., Hurvitz, E.A., Nelson, V.S., & Waring, W. (1998). Bowel management in children and
adolescents with spinal cord injury. The Journal of Spinal Cord Medicine, 21(4), 335-341.
Hardy, M.A. (1991). Normal changes with aging. In M. Maas, K.C. Buckwalter, & M. Hardy (Eds.),
Nursing
diagnoses and interventions for the elderly (pp. 145-146). Redwood City, CA: Addison-Wesley.
McLane, A.M., & McShane, R.E. (1991). Constipation. In M. Maas, K. Buckwalter, & M. Hardy (Eds.),
Nursing diagnoses and interventions for the elderly (pp. 147-158). Redwood City, CA: Addison-Wesley.
Mangan, P., & Thomas, L. (1988). Preserving dignity. Geriatric Nursing and Home Care, 8(9), 14.

NIC Definition & Activities Page 14 9-2006

Cast Care: Maintenance (CAST)
Definition: Care of a cast after the drying period.
Activities:
Apply sodium bicarbonate (baking soda) to an odiferous cast
Inspect cast for signs of drainage from wounds under the cast
Mark the circumference of any drainage as a gauge for future assessments
Apply plastic to cast if close to groin
Instruct patient not to scratch skin under the cast with any objects
Avoid getting a plaster cast wet
Position cast on pillows to lessen strain on other body parts
Check for cracking or breaks in the cast
Apply an arm sling for support, if appropriate
Pad rough cast edges and traction connections, as appropriate
Background Readings:
Beck, C.K., Rawlins, R.P., & Williams, S.R. (1988). Mental health-psychiatric nursing. St. Louis: Mosby.
Farrell, J. (1986). Illustrated guide to orthopedic nursing (3rd ed.). Philadelphia: J.B. Lippincott.
Feller, N.G., Stroup, K., & Christian, L. (1989). Helping staff nurses become mini-specialists: Cast care.
American Journal of Nursing, 89(7), 991-992.
Kozier, B., & Erb, G. (1989). Techniques in clinical nursing (3rd ed.). Menlo Park, CA: Addison-Wesley.
Perry, A.G., & Potter, P.A. (1998). Clinical nursing skills and techniques. (4th ed.) St. Louis: Mosby.
Smith, S., & Duell, D. (1992). Clinical nursing skills (3rd ed.). Los Altos, CA: National Nursing Review.

NIC Definition & Activities Page 15 9-2006

Chest Physiotherapy (CHEST)
Definition: Assisting the patient to move airway secretions from peripheral airways to more
central airways for expectoration and/or suctioning.
Activities:
Determine presence of contraindications for use of chest physical therapy
Determine which lung segment(s) needs to be drained
Position patient with the lung segment to be drained in uppermost position
Use pillows to support patient in designated position
Use percussion with postural drainage by cupping hands and clapping the chest wall in rapid
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succession to produce a series of hollow sounds
Use chest vibration in combination with postural drainage, as appropriate
Use an ultrasonic nebulizer, as appropriate
Use aerosol therapy, as appropriate
Administer bronchodilators, as appropriate
Administer mucokinetic agents, as appropriate
Monitor amount and type of sputum expectoration
Encourage coughing during and after postural drainage
Monitor patient tolerance by means of SaO2, respiratory rhythm and rate, cardiac rhythm and
rate,
and comfort levels
Background Reading:
Brooks-Brunn, J. (1986). Respiration. In L. Abels (Ed.), Critical care nursing: A physiologic approach
(pp.
168-253). St. Louis: Mosby.
Craven, R.F., & Hirnle, C.J. (2000) Fundamentals of nursing: Human health and function. (3rd ed.) (pp.
810813). Philadelphia: Lippincott.
Kiriloff, L.H., Owens, G.R., Rogers, R.M., & Mazzocco, M.C. (1985). Does chest physical therapy work?
Chest, 88, 436-444.
Nelson, D.M. (1992). Interventions related to respiratory care. In G.M. Bulechek & J.C. McCloskey
(Eds.),
Symposium on Nursing Interventions. Nursing Clinics of North America, 27(2), 301-324.
Sutton, P., Parker, R., Webber, B., Newman, S., Garland, N., Lapez-Vidriera, M., Pavia, D., & Clark, S.W.
(1983). Assessment of forced expiration technique, postural drainage, and directed coughing in chest
physiotherapy. European Journal of Respiratory Disease, 64, 62-68.

NIC Definition & Activities Page 16 9-2006

Contact Lens Care (EYECL)
Definition: Prevention of eye injury and lens damage by proper use of contact lenses.
Activities:
Wash hands thoroughly before touching the lenses
Clean lenses with the recommended sterile solution
Use recommended solutions to wet lenses
Store in a clean storage kit
Remove lenses at bedtime or at appropriate intervals for patient who cannot do this for self
Instruct patient how to examine lenses for damage
Instruct the patient to avoid irritating eye makeup
Avoid use of chemicals (e.g.; soaps, lotions, creams and sprays) near lenses because they may
damage the lenses
Make referral to eye specialist, as appropriate
Background Readings:
Perry, A.G. & Potter, P.A. (2002). Clinical nursing skills and techniques (5 th ed.). St. Louis: Mosby.

NIC Definition & Activities Page 17 9-2006

Counseling (COUNSEL and COUNSELG)
Definition1: Use of an interactive helping process focusing on the needs, problems, or
feelings of
the patient (or group) and significant others to enhance or support coping, problem solving,
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and interpersonal relationships.
Counseling (individual) COUNSEL
Counseling (group) COUNSELG
Activities:
Establish a therapeutic relationship based on trust and respect
Demonstrate empathy, warmth, and genuineness
Establish the length of the counseling relationship
Establish goals
Provide privacy and ensure confidentiality
Provide factual information as necessary and appropriate
Encourage expression of feelings
Assist patient to identify the problem or situation that is causing the distress
Use techniques of reflection and clarification to facilitate expression of concerns
Ask patient/significant others to identify what they can/cannot do about what is happening
Assist patient to list and prioritize all possible alternatives to a problem
Identify any differences between patient’s view of the situation and the view of the health care
team
Determine how family behavior affects patient
Verbalize the discrepancy between the patient’s feelings and behaviors
Use assessment tools (e.g., paper and pencil measures, audiotape, videotape, interactional
exercises
with other people) to help increase patient’s self-awareness and counselor’s knowledge of
situation, as appropriate
Reveal selected aspects of your own experiences or personality to foster genuineness and trust as
appropriate
Assist patient to identify strengths, and reinforce these
Encourage new skill development as appropriate
Encourage substitution of undesirable habits with desirable habits
Reinforce new skills
Discourage decision making when the patient is under severe stress, when possible
Background Readings:
Banks, L.J. (1992). Counseling. In G.M. Bulechek & J.C. McCloskey (Eds.), Nursing interventions:
Essential
nursing treatments (pp. 279-291). Philadelphia: W.B. Saunders.
Corey, G. (1991). Theory and practice of counseling and psychotherapy. (4th ed.). Pacific Grove, CA:
Brooks/Cole Publishing Company.
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definition differentiates between individual’s or group intervention.

NIC Definition & Activities Page 18 9-2006

Diarrhea Management (DIARR)
Definition: prevention and alleviation of diarrhea
Activities:
Determine history of diarrhea
Obtain stool for culture and sensitivity if diarrhea continues
Evaluate medication profile for gastrointestinal side effects
Teach patient appropriate use of antidiarrheal medications
Instruct patient/family members to record color, volume, frequency, and consistency of stools
Evaluate recorded intake for nutritional content
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Encourage frequent, small feedings, adding bulk gradually
Teach patient to eliminate gas-forming and spicy foods from diet
Suggest trial elimination of foods containing lactose
Identify factors (e.g., medications, bacteria, tube feedings) that may cause or contribute to
diarrhea
Monitor for signs and symptoms of diarrhea
Instruct patient to notify staff of each episode of diarrhea
Observe skin turgor regularly
Monitor skin in perianal area for irritation and ulceration
Measure diarrhea/bowel output
Weigh patient regularly
Notify physician of an increase in frequency or pitch of bowel sounds
Consult physician if signs and symptoms of diarrhea persist
Instruct in low-fiber, high-protein, high-calorie diet, as appropriate
Instruct in avoidance of laxatives
Teach patient/family how to keep a food diary
Teach patient stress-reduction techniques, as appropriate
Assist patient in performing stress-reduction techniques
Monitor safe food preparation
Perform actions to rest the bowel (e.g., NPO, liquid diet)
Background Readings:
Hogan, C.M. (1998) The nurse’s role in diarrhea management, Oncology Nurse Forum, 25(5), 879-886.
Taylor, C.M. (1987). Nursing diagnosis cards. Springhouse, PA: Springhouse Corporation.
Wadle, K. (2001) Diarrhea. In Maas, M.L., Buckwalter, K.C., Hardy, M.D., Reimer, T.T., Titler, M.G., &
Specht, J.P. (Eds.). (2001) Nursing care of older adults: Diagnoses, outcomes, & interventions (pp. 227237). St. Louis: Mosby.
Williams, M.S., Harper, R., Magnuson, B., Loan, T., Kearney, P. (1998). Diarrhea management in
enterally
fed patients. Nutrition in Clinical Problems, 13, 225-229.

NIC Definition & Activities Page 19 9-2006

Emergency Care (ERILL and ERINJ)
Definition1: Providing life-saving measures in life-threatening situations caused by illness
or
injury.
Emergency Care (illness) ERILL
Emergency Care (injury) ERINJ
Activities:
Act quickly and methodically, giving care to the most urgent conditions
Activate the emergency medical system
Instruct others to call for help, if needed
Maintain an open airway
Perform cardiopulmonary resuscitation, as appropriate
Perform the Heimlich maneuver, as appropriate
Move patient to a safe location, as appropriate
Check for medical alert tags
Apply manual pressure over bleeding site, as appropriate
Apply a pressure dressing, as needed
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Monitor the amount and nature of blood loss
Check for signs and symptoms of pneumothorax or flailing chest
Elevate injured part, as appropriate
Apply mast trousers, as appropriate
Monitor vital signs
Determine the history of the accident from the patient or others in the area
Determine whether an overdose of a drug or other substance is involved
Determine whether toxic or poisonous substances are involved
Send drugs believed to be affecting patient to treatment facility, as appropriate
Monitor level of consciousness
Immobilize fractures, large wounds, and any injured part
Monitor neurological status for possible head or spinal injuries
Apply a cervical collar, as appropriate
Maintain body alignment in suspected spinal injuries
Provide reassurance and emotional support to patient
Initiate medical transport, as appropriate
Transport using a back board, as appropriate
Background Readings:
Beaver, B.M. (1990). Care of the multiple trauma victim: The first hour. Nursing Clinics of North
America,
25(1), 11-22.
Laskowski-Jones, L. (2000) Responding to summer emergencies-education STATPack, Dimensions of
Critical
Care Nursing, 19(4), 11-12, July-August.
Smith, S., & Duell, D. (1992). Clinical nursing skills (3rd ed.). Los Altos, CA: National Nursing Review.
Sorensen, K., & Luckmann, J. (1986). Basic nursing: A psychophysiologic approach (2nd ed.).
Philadelphia:
W.B. Saunders.
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definition differentiates between intervention related to illness or injury.

NIC Definition & Activities Page 20 9-2006

Enteral Tube Feeding (TUBEFEED)
Definition: Delivering nutrients and water through a gastrointestinal tube.
Activities:
Explain the procedure to the patient
Insert a nasogastric, nasoduodenal, or nasojejunal tube according to agency protocol
Apply anchoring substance to skin and secure feeding tube with tape
Monitor for proper placement of the tube by inspecting oral cavity, checking for gastric residual, or listening while
air is
injected and withdrawn according to agency protocol
Mark the tubing at the point of exit to maintain proper placement
Confirm tube placement by x-ray examination prior to administering feedings or medications via the tube per
agency
protocol
Monitor for presence of bowel sounds every 4 to 8 hours, as appropriate
Monitor fluid and electrolyte status
Consult with other health care team members in selecting the type and strength of enteral feeding
Elevate head of the bed 30 to 45 degrees during feedings
Offer pacifier to infant during feeding, as appropriate
Hold and talk to infant during feeding to simulate usual feeding activities
Discontinue feedings 30 to 60 minutes before putting patient in a head-down position

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Turn off the tube feeding 1 hour prior to a procedure or if the patient needs to be in a position with the head less than
30
degrees
Irrigate the tube every 4 to 6 hours as appropriate during continuous feedings and after every intermittent feeding
Use clean technique in administering tube feedings
Check gravity drip rate or pump rate every hour
Slow tube feeding rate and/or decrease strength to control diarrhea
Monitor for sensation of fullness, nausea, and vomiting
Check residual every 4 to 6 hours for the first 24 hours, then every 8 hours during continuous feedings
Check residual before each intermittent feeding
Hold tube feedings if residual is greater than 150 cc or more than 110% to 120% of the hourly rate in adults
Keep cuff of endotracheal or tracheostomy tube inflated during feeding, as appropriate
Keep open containers of enteral feeding refrigerated
Change insertion site and infusion tubing according to agency protocol
Wash skin around skin level device daily with mild soap and dry thoroughly
Check water level in skin level device balloon according to equipment protocol
Discard enteral feeding containers and administration sets every 24 hours
Refill feeding bag every 4 hours, as appropriate
Monitor for presence of bowel sounds every 4 to 8 hours, as appropriate
Monitor fluid and electrolyte status
Monitor for growth (height/weight) changes monthly, as appropriate
Monitor weight 3 times weekly initially, decreasing to once a month
Monitor for signs of edema or dehydration
Monitor fluid intake and output
Monitor calorie, fat, carbohydrate, vitamin, and mineral intake for adequacy (or refer to dietitian) 2 times weekly
initially,
decreasing to once a month
Monitor for mood changes
Prepare individual and family for home tube feedings, as appropriate
Monitor weight at least three times a week, as appropriate for age
Background Readings:
Fellows, L.S., Miller, E.H., Frederickson, M, Bly, B., & Felt, P. (2000). Evidence-based practice for enteral feedings and
aspiration
prevention: Strategies, bedside detection and practice change. MEDSUR6 Nursing, 9(1), 27-31.
Mahan, K.L., & Escott-Stump, S. (2000) In Krause’s food, nutrition & diet therapy (9th ed.). Philadelphia: W.B. Saunders.
Methany, N.A. & Titler, M.G. (2001). Assessing placement of feeding tubes. American Journal of Nursing, 101(5), 6-45.
Perry, A.G., & Potter, P.A. (2002). Clinical nursing skills and techniques (5th ed.) (pp. 559-616). St. Louis: Mosby.

NIC Definition & Activities Page 21 9-2006

Environmental Management (ENVMGT)
Definition: Manipulation of the patient’s surroundings for therapeutic benefit, sensory appeal and
psychological well-being.
Activities:
Create a safe environment for the patient
Identify the safety needs of patient, based on level of physical and cognitive function and history of behavior
Remove environmental hazards (e.g., loose rugs and small, movable furniture)
Remove harmful objects from the environment
Safeguard with side rails/side-rail padding, as appropriate
Provide low-height bed, as appropriate
Provide adaptive devices (e.g., step stools or handrails), as appropriate
Place furniture in room in an appropriate arrangement that best accommodates patient or family disabilities
Provide sufficiently long tubing to allow freedom of movement, as appropriate
Place frequently used objects within reach
Consider the aesthetics of the environment when selecting furnishings
Provide a clean, comfortable bed and environment
Provide a firm mattress
Place bed-positioning switch within easy reach

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Reduce environmental stimuli, as appropriate
Avoid unnecessary exposure, drafts, overheating, or chilling
Adjust environmental temperature to meet patient’s needs, if body temperature is altered
Control or prevent undesirable or excessive noise, when possible
Provide music of choice
Provide headphones for private listening when music may disturb others
Manipulate lighting for therapeutic benefit
Provide attractively arranged meals and snacks
Clean areas used for eating and drinking utensils prior to patient use
Individualize daily routine to meet patient’s needs
Bring familiar objects from home
Facilitate use of personal items such as pajamas, robes, and toiletries
Maintain consistency of staff assignment over time
Provide immediate and continuous means to summon nurse, and let the patient and family know they will be
answered
immediately
Educate patient and visitors about the changes/precautions, so they will not inadvertently disrupt the planned
environment
Provide family/guardian with information about making home environment safe for patient
Promote fire safety, as appropriate
Control environmental pests, as appropriate
Provide room deodorizers, as needed
Background Readings:
Ackerman, L.L. (1992). Interventions related to neurological care. In G.M. Bulechek & J.C. McCloskey (Eds.), Symposium on Nursing
Interventions.
Nursing Clinics of North America, 27(2), 325-346.
Drury, J., & Akins, J. (1991). Sensory/perceptual alterations. In M. Maas, K. Buckwalter, & M. Hardy (Eds.), Nursing diagnoses and
interventions for
the elderly (pp. 369-389). Redwood City, CA: Addison-Wesley.
Gerdner, L., & Buckwalter, K. (1999). Music therapy. In G. Bulechek & J. McCloskey (Eds.), Nursing interventions: Effective nursing treatments
(3rd
ed.) (pp. 451-468). Philadelphia: W.B. Saunders.
Phylar, P.A. (1989). Management of the agitated and aggressive head injury patient in an acute hospital setting. Journal of Neuroscience Nursing,
21(6),
353-356.
Schuster, E., & Keegan, L. (2000). Environment. In B. Dossey, L. Keegan, & C. Guzzetta. Holistic nursing: A handbook for practice (3rd ed.) (pp.
249282). Gaithersburg, MD: Aspen Publishers.
Stoner, N. (1999). Feeding. In G. Bulechek & J. McCloskey (Eds.) Nursing interventions: Effective nursing treatments (3rd ed.) (pp. 31-46).
Philadelphia: W.B. Saunders.

NIC Definition & Activities Page 22 9-2006

Exercise Promotion (EXER and EXERG)
Definition1: Facilitating a patient of a group of patients in regular physical exercise to
maintain
or advance to a higher level of fitness and health.
Exercise Promotion (individual) EXER
Exercise Promotion (group) EXERG
Activities:
Appraise individual’s health beliefs about physical exercise
Explore prior exercise experiences
Determine individual’s motivation to begin/continue exercise program
Explore barriers to exercise
Encourage verbalization of feelings about exercise or need for exercise
Encourage individual to begin or continue exercise
Assist in identifying a positive role model for maintaining the exercise program
Assist individual to develop an appropriate exercise program to meet needs
Assist individual to set short-term and long-term goals for the exercise program
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Assist individual to schedule regular periods for the exercise program into weekly routine
Perform exercise activities with individual, as appropriate
Include family/caregivers in planning and maintaining the exercise program
Inform individual about health benefits and physiological effects of exercise
Instruct individual about appropriate type of exercise for level of health, in collaboration with physician
and/or
exercise physiologist
Instruct individual about desired frequency, duration, and intensity of the exercise program
Monitor individual’s adherence to exercise program/activity
Assist individual to prepare and maintain a progress graph/chart to motivate adherence to the exercise
program
Instruct individual about conditions warranting cessation of or alteration in the exercise program
Instruct individual on proper warm-up and cool-down exercises
Instruct individual in techniques to avoid injury while exercising
Instruct individual in proper breathing techniques to maximize oxygen uptake during physical exercise
Provide reinforcement schedule to enhance individual’s motivation (e.g., increased endurance estimation;
weekly weigh-in)
Monitor individual’s response to exercise program
Provide positive feedback for individual’s efforts

Background Readings:
Allan, J.D., & Tyler, D.O. (1999). Exercise promotion. In G.M. Bulechek & J.C. McCloskey (Eds.), Nursing
interventions: Effective nursing treatments (3rd ed.) (pp. 130-148). Philadelphia: W.B. Saunders.
Glick, O.J. (1992). Interventions related to activity and movement. In G.M. Bulechek & J.C. McCloskey (Eds.),
Symposium on Nursing Interventions. Nursing Clinics of North America, 27(2), 541-568.
NIH Consensus Development Panel on Physical Activity and Cardiovascular Health. (1996). Physical activity and
cardiovascular health. Journal of the American Medical Association, 276 (3), 241-246.
Rippe, J., Ward, A., Porcari, J. et al. (1989). The cardiovascular benefits of walking. Practical Cardiology, 15(1).
Sorenson, S., & Poh, A. (1989). Physical fitness. In P. Swinford & J. Webster (Eds.), Promoting wellness: A nurse’s
handbook (pp. 101-140). Rockville, MD: Aspen.
Timmermans, H., & Martin, M. (1987). Top ten potentially dangerous exercises. Journal of Physical Education,
Recreation and Dance, 58, 29.
Topp, R. (1991). Development of an exercise program for older adults: Pre-exercise testing, exercise prescription
and
program maintenance. Nurse Practitioner, 16(10), 16-28.
1 Delaware definition differentiates between individual or group intervention.

NIC Definition & Activities Page 23 9-2006

Feeding (FEED)
Definition1: Feeding of patient with oral motor deficits.
Activities:
Identify prescribed diet
Set food tray and table attractively
Create a pleasant environment during mealtime (e.g., put bedpans, urinals, and suctioning
equipment
out of sight)
Provide for adequate pain relief before meals, as appropriate
Provide for oral hygiene before meals
Identify presence of swallowing reflex, if necessary
Sit down while feeding to convey pleasure and relaxation
Offer opportunity to smell foods to stimulate appetite
Ask patient preference for order of eating
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Fix foods as patient prefers
Maintain patient in an upright position, with head and neck flexed slightly forward during
feeding
Place food in the unaffected side of the mouth, as appropriate
Follow feedings with water, if needed
Protect patient’s clothing with a bib, as appropriate
Ask the patient to indicate when finished, as appropriate
Record intake, if appropriate
Avoid disguising drugs in food
Provide a drinking straw, as needed or desired
Provide finger foods, as appropriate
Provide foods at most appetizing temperature
Avoid distracting patient during swallowing
Feed unhurriedly/slowly
Postpone feeding, if patient is fatigued
Encourage parents/family to feed patient
Background Readings:
Evans-Stoner, N.J. (1999). Feeding. In G.M. Bulechek & J.C. McCloskey (Eds.), Nursing interventions:
Effective nursing treatments (3rd ed.) (pp. 31-46). Philadelphia: W.B. Saunders.
Styker, R. (1977). Rehabilitative aspects of acute and chronic nursing care. Philadelphia: W.B. Saunders.
1 Delaware

definition; NIC definition reads providing nutritional intake for patient who is unable to feed self.

NIC Definition & Activities Page 24 9-2006

Fever Treatment (FVR)
Definition: Management of a patient with hyperpyrexia caused by nonenvironmental
factors.
Activities:
Monitor temperature as frequently as is appropriate
Monitor for insensible fluid loss
Institute a continuous core temperature–monitoring device, as appropriate
Monitor skin color and temperature
Monitor blood pressure, pulse, and respiration, as appropriate
Monitor for decreasing levels of consciousness
Monitor for seizure activity
Monitor intake and output
Monitor for presence of cardiac arrhythmias
Administer antipyretic medication, as appropriate
Administer medications to treat the cause of fever, as appropriate
Cover the patient with a sheet, only as appropriate
Encourage increased intake of oral fluids, as appropriate
Increase air circulation by using a fan
Encourage or administer oral hygiene, as appropriate
Give appropriate medication to prevent or control shivering
Administer oxygen, as appropriate
Monitor temperature closely to prevent treatment-induced hypothermia
Background Readings:
Beutler, B., & Beutler, S. (1992). Pathogenesis of fever. In J.B. Wyngaarden, L.H. Smith, Jr., & J.C.
Bennett,
328

Jr. (Eds.), Cecil textbook of medicine (19th ed.) (pp. 1568-1571). Philadelphia: W.B. Saunders.
Thompson, J.M., McFarland, G.K., Hirsch, J.E., & Tucker, S.M. (1993). Mosby’s clinical nursing (3rd
ed.). St.
Louis: Mosby.

NIC Definition & Activities Page 25 9-2006

First Aid (WOUNDFA)
Definition: Providing initial care for a minor injury.
Activities:
Control bleeding
Immobilize the affected body part, as appropriate
Elevate the affected body part
Apply a sling, if appropriate
Cover any open or exposed bony parts
Apply ice to the affected body part, as appropriate
Monitor vital signs, as appropriate
Cool the skin with water in cases of minor burns
Flood with water any tissue exposed to a chemical irritant
Remove the stinger from an insect bite, as appropriate
Remove the tick from the skin, as appropriate
Cleanse and remove secretions from the area around a nonpoisonous snake bite
Cover patient with a blanket, as appropriate
Instruct to seek further medical care, as appropriate
Coordinate emergency transport, as needed
Background Readings:
Arnold, R.E. (1973). What to do about bites and stings from venomous animals. New York: Macmillan.
Bizjak, G., Elling, B., Gaull, E.S., & Linn, D. (1994). Emergency care (6th ed.). Englewood Cliffs, NJ:
Prentice Hall.
Judd, R.L. (1982). The first responder: The critical first minutes. St. Louis: Mosby.
Phillips, C. (1986). Basic life support skills manual: For EMT-As and first responders. Bowie, MD:
Brady.
Sorensen, K., & Luckmann, J. (1986). Basic nursing: A psychophysiologic approach (2nd ed.).
Philadelphia:
W.B. Saunders.

NIC Definition & Activities Page 26 9-2006

Health Care Information Exchange (INFOILL and INFOINJ)
Definition1: Providing patient care information to other health professionals related to
illness
or injury.
Health Care Information Exchange (illness) INFOILL
Health Care Information Exchange (injury) INFOINJ
Activities:
Identify referring nurse and location
Identify essential demographic data
Describe pertinent health history
Identify current nursing and medical diagnoses
Identify resolved nursing and medical diagnoses, as appropriate
Describe plan of care, including diet, medications, and exercise
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Describe nursing interventions being implemented
Identify equipment and supplies necessary for care
Summarize progress of patient toward goals
Identify anticipated date of discharge or transfer
Identify planned return appointment for follow-up care
Describe role of family in continuing care
Identify capabilities of patient and family in implementing care after discharge
Identify other agencies providing care
Request information from health professionals in other agencies
Coordinate care with other health professionals
Discuss patient’s strengths and resources
Share concerns of patient or family with other health care providers
Share information from other health professionals with patient and family, as appropriate
Background Readings:
Jenkins, C.A., Schullz, M., Hanson, J., Bruera. E. (2000). Demographic, symptom and medication
profiles of
cancer patients seen by a palliative care consult team in a tertiary referral hospital. Journal of Pain &
Symptom Management 19(3), 174-184.
Job, T. (1999). A system for determining the priority of referrals within a multidisciplinary community
mental
health team. British Journal of Occupation Therapy 62(11), 486-490.
Kron, T., & Gray, A. (1987). The management of patient care. Putting leadership skills to work (6th ed.).
Philadelphia: W.B. Saunders.
Smith, F.A. (2000). The function of consumer health information centers in hospitals. Medical Library
Association News 327(Jun-Jul), 23.
Summerton, H. (1998). Clinical management. Discharge planning: Establishing an effective coordination
team. British Journal of Nursing 7(20), 1263-7.
1 Delaware

definition differentiates between intervention related to illness or injury.

NIC Definition & Activities Page 27 9-2006

Health Education (HLTHED and HLTHEDG)
Definition1: Developing and providing individual or group instruction and learning experiences to facilitate
voluntary adaptation of behavior conducive to health in individuals, families, groups, or communities.
Health Education (individual) HLTHED
Health Education (group) HLTHEDG

Activities:
Target high-risk groups and age ranges that would benefit most from health education
Target needs identified in Healthy People 2000: National Health Promotion and Disease Prevention Objectives or other local,
state, and
national needs
Identify internal or external factors that may enhance or reduce motivation for healthy behavior
Determine personal context and social-cultural history of individual, family, or community health behavior
Determine current health knowledge and lifestyle behaviors of individual, family, or target group
Assist individuals, families, and communities in clarifying health beliefs and values
Identify characteristics of target population that affect selection of learning strategies
Prioritize identified learner needs based on client preference, skills of nurse, resources available, and likelihood of successful goal
attainment
Formulate objectives for health education program
Identify resources (e.g., personnel, space, equipment, money) needed to conduct program
Consider accessibility, consumer preference, and cost in program planning
Strategically place attractive advertising to capture attention of target audience
Avoid use of fear or scare techniques as strategy to motivate people to change health or lifestyle behaviors
Emphasize immediate or short-term positive health benefits to be received by positive lifestyle behaviors rather than long-term
benefits

330

or negative effects of noncompliance
Incorporate strategies to enhance the self-esteem of target audience
Develop educational materials written at a reading level appropriate to target audience
Teach strategies that can be used to resist unhealthy behavior or risk taking rather than give advice to avoid or change behavior
Keep presentation focused, short, and beginning and ending on main point
Use group presentations to provide support and lessen threat to learners experiencing similar problems or concerns, as
appropriate
Use peer leaders, teachers, and support groups in implementing programs to groups less likely to listen to health professionals or
adults
(e.g., adolescents), as appropriate
Use lectures to convey the maximum amount of information when appropriate
Use group discussions and role-playing to influence health beliefs, attitudes, and values
Use demonstrations/return demonstrations, learner participation, and manipulation of materials when teaching psychomotor skills
Use computer-assisted instruction, television, interactive video, and other technologies to convey information
Use teleconferencing, telecommunications, and computer technologies for distance learning
Involve individuals, families, and groups in planning and implementing plans for lifestyle or health behavior modification
Determine family, peer, and community support for behavior conducive to health
Utilize social and family support systems to enhance effectiveness of lifestyle or heath behavior modification
Emphasize importance of healthy patterns of eating, sleeping, exercising, etc. to individuals, families, and groups who model
these
values and behaviors to others, particularly children
Use variety of strategies and intervention points in educational program
Plan long-term follow-up to reinforce health behavior or lifestyle adaptations
Design and implement strategies to measure client outcomes at regular intervals during and after completion of program
Design and implement strategies to measure program and cost-effectiveness of education, using these data to improve the
effectiveness
of subsequent programs
Influence development of policy that guarantees health education as an employee benefit
Encourage policy whereby insurance companies give consideration for premium reductions or benefits for healthful lifestyle
practices

Background Readings:
APHA Technical Report. (1987). Criteria for the development of health promotion and education programs. American Journal of Public Health,
77 (1),
89-92.
Bastable, S.B. (2003). Nurse as educator: Principles of teaching and learning for nursing practice. Boston: Jones and Bartlett Publishers.
Clark, M.J. (1992). Nursing in the community. The health education process (pp. 126-141). Norfolk, CT: Appleton & Lange.
Damrosch, S. (1991). General strategies for motivating people to change their behavior. Nursing Clinics of North America, 26(4), 833-843.
Department of Health and Human Services. (1991). Healthy People 2000: National health promotion and disease prevention objectives (DHHS
Publication No. PHS 91-50213). Washington, DC. U.S. Government Printing Office.
Green, L.W., & Johnson, K.W. (1983). Health education and health promotion. In D. Mechanic (Ed.), Handbook of health, health care, and the
health
professional (pp. 744-765). New York: The Free Press, Macmillan Publishing Co.
Somas Job, R.F. (1988). Effective and ineffective use of fear in health promotion campaigns. American Journal of Public Health, 78(2), 163-167.
Pahnos, M.L. (1992). The continuing challenge of multicultural health education. Journal of School Health 62(1), 24-26.
1 Delaware

definition differentiates between individual or group intervention.

NIC Definition & Activities Page 28 9-2006

Health System Guidance (HGUIDE)
Definition: Facilitating a patient’s location and use of appropriate health services.
Activities:
Explain the immediate health care system, how it works, and what the patient/family can expect
Assist patient or family to coordinate health care and communication
Assist patient or family to choose appropriate health care professionals
Instruct patient on what type of services to expect from each type of health care provider (e.g., nurse
specialists, registered dietitians, registered nurses, licensed practical nurses, physical therapists,
cardiologists, internists, optometrists, and psychologists)
Inform the patient about different types of health care facilities (e.g., general hospital, specialty hospital,
teaching hospital, walk-in clinic, and outpatient surgical clinic), as appropriate
Inform the patient of accreditation and state health department requirements for judging the quality of a
facility
331

Inform patient of appropriate community resources and contact persons
Advise use of second opinion
Inform patient of right to change health care provider
Inform the patient as to the meaning of signing a consent form
Provide patient with copy of Patient’s Bill of Rights
Inform patient how to access emergency services by telephone and vehicle, as appropriate
Encourage patient to go to the emergency department, if appropriate
Identify and facilitate communication among health care providers and patient/family, as appropriate
Inform patient/family how to challenge decision made by a health care provider, as needed
Encourage consultation with other health care professionals, as appropriate
Request services from other health professionals for patient, as appropriate
Coordinate referrals to relevant health care providers, as appropriate
Review and reinforce information given by other health care professionals
Provide information on how to obtain equipment
Coordinate/schedule time needed by each service to deliver care, as appropriate
Inform patient of the cost, time, alternatives, and risks involved in a specific test or procedure
Give written instructions for purpose and location of post-hospitalization/outpatient activities, as
appropriate
Give written instructions for purpose and location of health care activities, as appropriate
Discuss outcome of visit with other health care providers, as appropriate
Identify and facilitate transportation needs for obtaining health care services
Provide follow-up contact with patient, as appropriate
Monitor adequacy of current health care follow-up
Provide report to post-hospital caregivers, as appropriate
Encourage the patient/family to ask questions about services and charges
Comply with regulations for third-party reimbursement
Assist individual to complete forms for assistance, such as housing and financial aid, as needed
Notify patient of scheduled appointments, as appropriate
Inform individual/family of available healthcare insurance

Background Readings:
Arnold, E., & Boggs, K. (1989). Interpersonal relationships: Professional communication skills for nurses.
Philadelphia:
W.B. Saunders.
Dunne, P.J. (1998). The emerging health care delivery system. American Association of Respiratory Care (AARC)
Times
22(1), 24-8.
Matthews, P. (2000). Planning for successful outcomes in the new millennium. Topics in Health Information
Management 20(3), 55-64.
Viscardis, L. (1998). The family-centered approach to providing services: A parent perspective. Physical &
Occupation
Therapy in Pediatrics 18(1), 41-53.
Zarbock, S.G. (1999). Sharing in all dimensions: Providing nourishment at home. Home Care Provider 4(3), 106107.

NIC Definition & Activities Page 29 9-2006

Heat/Cold Application (Injury1) (HTCLD)
Definition: Stimulation of the skin and underlying tissues with heat or cold for the purpose
of
decreasing pain, muscle spasms, or inflammation.
Activities:
Explain the use of heat or cold, the reason for the treatment, and how it will affect the patient’s symptoms

332

Screen for contraindications to cold or heat, such as decreased or absent sensation, decreased circulation,
and
decreased ability to communicate
Select a method of stimulation that is convenient and readily available, such as waterproof plastic bags
with
melting ice; frozen gel packs; chemical ice envelope; ice immersion; cloth or towel in freezer for cold; hot
water bottle; electric heating pad; hot, moist compresses; immersion in tub or whirlpool; paraffin wax;
sitz
bath; radiant bulb; or plastic wrap for heat
Determine availability and safe working condition of all equipment used for heat or cold application
Determine condition of skin and identify any alterations requiring a change in procedure or
contraindications
to stimulation
Select stimulation site, considering alternate sites when direct application is not possible (e.g., adjacent to,
distal to, between affected areas and the brain, and contralateral)
Wrap the heat/cold application device with a protective cloth, if appropriate
Use a moist cloth next to the skin to increase the sensation of cold/heat, when appropriate
Instruct how to avoid tissue damage associated with heat/cold
Check the temperature of the application, especially when using heat
Determine duration of application based on individual verbal, behavioral, and biological responses
Time all applications carefully
Apply cold/heat directly on or near the affected site, if possible
Inspect the site carefully for signs of skin irritation or tissue damage throughout the first 5 minutes and
then
frequently during the treatment
Evaluate general condition, safety, and comfort throughout the treatment
Position to allow movement from the temperature source, if needed
Instruct not to adjust temperature settings independently without prior instruction
Change sites of cold/heat application or switch form of stimulation, if relief is not achieved
Instruct that cold application may be painful briefly, with numbness about 5 minutes after the initial
stimulation
Instruct on indications for, frequency of, and procedure for application
Instruct to avoid injury to the skin after stimulation
Evaluate and document response to heat/cold application

Background Readings:
Herr, K.A., & Mobily, P.R. (1992). Interventions related to pain. In G.M. Bulechek & J.C. McCloskey (Eds.),
Symposium on Nursing Interventions. Nursing Clinics of North America, 27(2), 347-370.
McCaffery, M., & Beebe, A. (1989). Pain. Clinical manual for nursing practice (pp. 145-154). St. Louis: Mosby.
Perry, A.G., & Potter, P.A. (1998). Clinical nursing skills and techniques (pp. 1113-1132). St. Louis: Mosby.
Ridgeway, S., Brauer, D., Cross, J., Daniels, J.S., & Steffes, M. (1998). Application of heat and cold. In M. Snyder
& R.
Lindquist. (Eds.), Complementary/alternative therapies in nursing (3rd ed.) (pp. 89-102). New York: Springer
Publishing Company.
Sorensen, K., & Luckmann, J. (1986). Basic nursing: A psychophysiologic approach (2nd ed.) (pp. 966-981).
Philadelphia: W.B. Saunders.
1 Delaware definition limits to injury.

NIC Definition & Activities Page 30 9-2006

Heat Exposure Treatment (HEATX)
Definition: Management of patient overcome by heat due to excessive environmental heat
exposure.
Activities:
333

Remove patient from direct sunlight and/or heat source
Loosen or remove clothing, as appropriate
Wet the body surface and fan the patient
Give cool oral fluids if patient is able to swallow
Provide fluids rich in electrolytes, such as Gatorade
Transport to a cool environment, as appropriate
Determine the cause as exertional or nonexertional
Monitor level of consciousness
Monitor for hypoglycemia
Monitor for hypotension, cardiac arrhythmias, and signs of respiratory distress
Teach measures to prevent heat exhaustion and heat stroke
Teach early indications of heat exhaustion and appropriate actions to take
Background Readings:
Davis, L. (1997). Environmental heat-related illnesses. MedSurg Nursing, 6 (3), 153-161.
Knochel, J.P. (1992). Disorders due to heat and cold. In J.B. Wyngaarden, L.H. Smith, Jr., & J.C. Bennett,
Jr.
(Eds.), Cecil textbook of medicine (19th ed.) (pp. 2358-2361). Philadelphia: W.B. Saunders.
Thompson, J.M., McFarland, G.K., Hirsch, J.E., & Tucker, S.M. (1998). Mosby’s clinical nursing (4th
ed.). St.
Louis: Mosby– Year Book.

NIC Definition & Activities Page 31 9-2006

Hemorrhage Control (HMRR)
Definition: Reduction or elimination of rapid and excessive blood loss.
Activities:
Apply a pressure dressing, as indicated
Identify the cause of the bleeding
Monitor the amount and nature of blood loss
Apply manual pressure over the bleeding or the potential bleeding area
Apply ice pack to affected area
Evaluate patient’s psychological response to hemorrhage and perception of events
Inspect for bleeding from mucous membranes, bruising after minimal trauma, oozing from
puncture
sites, and presence of petechiae
Monitor for signs and symptoms of persistent bleeding (e.g., check all secretions for frank or
occult
blood)
Monitor neurological functioning
Background Readings:
Cullen, L.M. (1992). Interventions related to circulatory care. In G.M. Bulechek & J.C. McCloskey
(Eds.),
Symposium on Nursing Interventions. Nursing Clinics of North America, 27(2), 445-478.
Kitt, S., & Karser, J. (1990). Emergency nursing: A physiological and clinical perspective. Philadelphia:
W.B.
Saunders.
Thompson, J.M., McFarland, G.K., Hirsch, J.E., & Tucker, S.M. (1998). Mosby’s clinical nursing (4th
ed.). St.
Louis: Mosby.

NIC Definition & Activities Page 32 9-2006
334

High-Risk Pregnancy Care (PREG)
Definition: Identification and management of a high-risk pregnancy to promote healthy
outcomes for mother and baby.
Activities:
Determine the presence of medical factors that are related to poor pregnancy outcome (e.g., diabetes, hypertension,
lupus
erythmatosus, herpes, hepatitis, HIV, and epilepsy)
Review obstetrical history for pregnancy-related risk factors (e.g., prematurity, postmaturity, preeclampsia,
multifetal
pregnancy, intrauterine growth retardation, abruption, previa, Rh sensitization, premature rupture of membranes, and
family history of genetic disorder)
Recognize demographic and social factors related to poor pregnancy outcome (e.g., maternal age, race, poverty, late
or no
prenatal care, physical abuse, and substance abuse)
Determine client’s knowledge of identified risk factors
Encourage expression of feelings and fears about lifestyle changes, fetal well-being, financial changes, family
functioning, and personal safety
Provide educational materials that address the risk factors and usual surveillance tests and procedures
Instruct client in self-care techniques to increase the chance of a healthy outcome (e.g., hydration, diet, activity
modifications, importance of regular prenatal check-ups, normalization of blood sugars, and sexual precautions,
including abstinence)
Instruct about alternate methods of sexual gratification and intimacy
Refer as appropriate for specific programs (e.g., smoking cessation, substance abuse treatment, diabetes education,
preterm birth prevention education, abuse shelter, and sexually transmitted disease clinic)
Instruct client on use of prescribed medication (e.g., insulin, tocolytics, antihypertensives, antibiotics,
anticoagulants, and
anticonvulsants)
Instruct client on self-monitoring skills, as appropriate (e.g., vital signs, blood glucose testing, uterine activity
monitoring,
and continuous subcutaneous medication delivery)
Write guidelines for signs and symptoms that require immediate medical attention (e.g., bright red vaginal bleeding,
change in amniotic fluid, decreased fetal movement, four or more contractions/hour before 37 weeks of gestation,
headache, visual disturbances, epigastic pain, and rapid weight gain with facial edema)
Discuss fetal risks associated with preterm birth at various gestational ages
Tour the neonatal intensive care unit if preterm birth is anticipated (e.g., multifetal pregnancy)
Teach fetal movement counts
Establish plan for clinic follow-up
Provide anticipatory guidance for likely interventions during birth process (e.g., Electronic Fetal Monitoring:
Intrapartum,
Labor Suppression, Labor Induction, Medication Administration, Cesarean Section Care)
Encourage early enrollment in prenatal classes or provide childbirth education materials for patients on bed rest
Provide anticipatory guidance for common experiences that high-risk mothers have during the postpartum period
(e.g.,
exhaustion, depression, chronic stress, disenchantment with childbearing, loss of income, partner discord, and sexual
dysfunction)
Refer to high-risk mother support group, as needed
Refer to home care agencies (e.g., specialized perinatal nursing services, perinatal case management, and public
health
nursing)
Monitor physical and psychosocial status closely throughout pregnancy
Report deviations from normal in maternal and/or fetal status immediately to physician or nurse midwife
Document client education, lab results, fetal testing results, and client responses

Background Readings:
Association of Women’s Health, Obstetric, and Neonatal Nurses. (1993). Didactic content and clinical skills verification for
professional nurse providers of basic, high-risk and critical-care intrapartum nursing. Washington, DC: AWHONN.

335

Field, P.A., & Marck, P. (1994). Uncertain motherhood: Negotiating the risks of the childbearing years. Newbury Park, CA: Sage
Publishing.
Gilbert, E.S., & Harmon, J.S. (1998). Manual of high risk pregnancy and delivery. (2nd ed.). St. Louis: Mosby.
Mandeville, L.K., & Troiano, N.H. (Eds.). (1992). High-risk intrapartum nursing. Philadelphia: J.B. Lippincott.
Mattson, S. & J.E. Smith (Eds.). (1993). Core curriculum for maternal-newborn nursing. Philadelphia: W.B. Saunders.

NIC Definition & Activities Page 33 9-2006

Hyperglycemia Management (HYPERG)
Definition: Preventing and treating above-normal blood glucose levels.
Activities:
Monitor blood glucose levels, as indicated
Monitor for signs and symptoms of hyperglycemia: polyuria, polydipsia, polyphagia, weakness,
lethargy, malaise, blurring of vision, or headache
Monitor urine ketones, as indicated
Monitor ABG, electrolyte, and betahydroxybutyrate levels, as available
Monitor orthostatic blood pressure and pulse, as indicated
Administer insulin, as prescribed
Encourage oral fluid intake
Consult physician if signs and symptoms of hyperglycemia persist or worsen
Assist with ambulation if orthostatic hypotension is present
Provide oral hygiene, if necessary
Identify possible cause of hyperglycemia
Anticipate situations in which insulin requirements will increase (e.g., intercurrent illness)
Restrict exercise when blood glucose levels are >250 mg/dl, especially if urine ketones are
present
Instruct patient/family and significant others on prevention, recognition, and management of
hyperglycemia
Encourage self-monitoring of blood glucose levels
Assist patient to interpret blood glucose levels
Review blood glucose records with patient and/or family
Instruct on urine ketone testing, as appropriate
Instruct on indications for, and significance of, urine ketone testing, if appropriate
Instruct patient to report moderate or high urine ketone levels to the health professional
Instruct patient/family and significant others on diabetes management during illness, including
use of
insulin and/or oral agents; monitoring fluid intake; carbohydrate replacement; and when to seek
health professional assistance, as appropriate
Provide assistance in adjusting regimen to prevent and treat hyperglycemia (e.g., increasing
insulin or
oral agent), as indicated
Facilitate adherence to diet and exercise regimen
Test blood glucose levels of family members
Background Readings:
Guthrie, D.W. (Ed.). (1988). Diabetes education: Core curriculum for health professionals. Chicago:
American
Association of Diabetes Educators.
Thompson, J.M., McFarland, G.K., Hirsch, J.E., & Tucker, S.M. (1998). Mosby’s clinical nursing (4th
ed.). St.
Louis: Mosby.
336

NIC Definition & Activities Page 34 9-2006

Hypoglycemia Management (HYPOG)
Definition: Preventing and treating low blood glucose levels.
Activities:
Identify patient at risk for hypoglycemia
Determine recognition of hypoglycemia signs and symptoms
Monitor blood glucose levels, as indicated
Monitor for signs and symptoms of hypoglycemia (e.g., shakiness, tremor, sweating, nervousness,
anxiety,
irritability, impatience, tachycardia, palpitations, chills, clamminess, light-headedness, pallor, hunger,
nausea, headache, tiredness, drowsiness, weakness, warmth, dizziness, faintness, blurred vision,
nightmares, crying out in sleep, paresthesias, difficulty concentrating, difficulty speaking, incoordination,
behavior change, confusion, coma, seizure)
Provide simple carbohydrate, as indicated
Provide complex carbohydrate and protein, as indicated
Administer glucagon, as indicated
Contact emergency medical services, as necessary
Maintain patent airway, as necessary
Protect from injury, as necessary
Review events prior to hypoglycemia to determine probable cause
Provide feedback regarding appropriateness of self-management of hypoglycemia
Instruct patient/family and significant others on signs and symptoms, risk factors, and treatment of
hypoglycemia
Instruct patient to have simple carbohydrate available at all times
Instruct patient to obtain and carry/wear appropriate emergency identification
Instruct significant others on the use and administration of glucagon, as appropriate
Instruct on interaction of diet, insulin/oral agents, and exercise
Provide assistance in making self-care decisions to prevent hypoglycemia, (e.g., reducing insulin/oral
agents
and/or increasing food intake for exercise)
Encourage self-monitoring of blood glucose levels
Encourage ongoing telephone contact with diabetes care team for consultation regarding adjustments in
treatment regimen
Collaborate with patient and diabetes care team to make changes in insulin regimen (e.g., multiple daily
injections), as indicated
Modify blood glucose goals to prevent hypoglycemia in the absence of hypoglycemia symptoms
Inform patient of increased risk of hypoglycemia with intensive therapy and normalization of blood
glucose
levels
Instruct patient regarding probable changes in hypoglycemia symptoms with intensive therapy and
normalization of blood glucose levels

Background Readings:
American Diabetes Association. (1995). Intensive diabetes management. Alexandria, VA: Author.
American Diabetes Association. (1994). Medical management of insulin-dependent (type I) diabetes. (2nd ed.).
Alexandria, VA: Author.
Ahern, J., & Tamborlane, W.V. (1997). Steps to reduce the risks of severe hypoglycemia. Diabetes Spectrum, 10(1),
3941.
Cryer, P.E., Fisher J.N., & Shamoon, H (1994). Hypoglycemia. Diabetes Care, 17(7), 734-755.
Havlin, C.E., & Cryer, P.E. (1988). Hypoglycemia: The limiting factor in the management of insulin-dependent
diabetes

337

mellitus. Diabetes Educator, 14(5), 407-411.
Levandoski, L.A. (1993). Hypoglycemia. In V. Peragallo-Dittko (Ed.), A core curriculum for diabetes education (pp.
351372). Chicago: American Association of Diabetes Educators and AADE Education and Research Foundation.

NIC Definition & Activities Page 35 9-2006

Immunization Management (IZMGT)
Definition: Monitoring immunization status and facilitating access to immunizations to
prevent
communicable disease.
Activities:
Teach parent(s) recommended immunization necessary for children, their route of medication administration,
reasons and
benefits of use, adverse reactions, and side effects schedule (e.g.; hepatitis B, diphtheria, tetanus, pertussis,
Haemophilus influenza, polio, measles, mumps, rubella, and varicella)
Inform individuals of immunization protective against illness but not presently required by law (e.g.; influenza,
pneumonia, and hepatitis B vaccinations)
Teach individual/families about vaccinations available in the event of special incidence and/or exposure (e.g.;
cholera,
influenza, plague, rabies, Rocky Mountain spotted fever, smallpox, typhoid fever, typhus, yellow fever, and
tuberculosis)
Provide vaccine information statements prepared by CDC
Provide and update diary for recording date and type of immunizations
Identify proper administration techniques, including simultaneous administration
Note patient’s medical history and history of allergies
Administer injections to infant in the anterolateral thigh, as appropriate
Document vaccination information per agency protocol (e.g.; manufacturer, lot number, expiration date)
Inform families which immunizations are required by law for entering preschool, kindergarten, junior high, high
school,
and college
Audit school immunization records for completeness on a yearly basis
Notify individual/family when immunizations are not up-to-date
Follow the American Academy of Pediatrics, American Academy of Family Physicians, and U.S. Public Health
Service
guidelines for immunization administration
Inform travelers of vaccinations appropriate for travel to foreign countries
Identify true contraindications for administering immunizations (anaphylactic reaction to previous vaccine and
moderate
or severe illness with or without fever)
Recognize that a delay in series administration does not indicate restarting the schedule
Secure informed consent to administer vaccine
Help family with financial planning to pay for immunizations (e.g.; insurance coverage and health department
clinics)
Identify providers who participate in Federal “Vaccine for Children” program to provide free vaccines
Inform parent(s) of comfort measures helpful after medication administration to child
Observe patient for a specified period after medication administration
Schedule immunizations at appropriate time intervals
Determine immunization status at every health care visit (including emergency department and hospital admission),
and
provide immunizations as needed
Advocate for programs and policies that provide free or affordable immunizations to all populations
Support national registry to track immunization status

Background Readings:
Centers for Disease Control. (1997). Recommended childhood immunization schedule: United States 1997. Mortality and
Morbidity
Weekly Report, 46(2), 35-40.

338

Centers for Disease Control. (2002). Recommended adult immunization schedule: United States, 2002-2003. Mortality and
Morbidity
Weekly Report, 51(40), 904-908.
Lambert, J. (1995). Every child by two. A program of the American Nurses Foundation. American Nurse, 27(8), 12.
Lerner-Durjava, L. (1998). Nurse’s guide to immunizations. Nursing 28(7), 32hn10-12.
Scudder, L. (1995). Child immunization initiative: Politics and health policy in action. Nursing Policy Forum, 1 (3), 20-29.
Scarbrough, M.L., & Landis, S.E. (1997). A pilot study for the development of a hospital-based immunization program. Clinical
Nurse
Specialist, 11(2), 70-75.
West, A.R., & Kopp, M. (1999). Making a difference: Immunizing infants and children. American Nurse Foundation, A1-A6.

NIC Definition & Activities Page 36 9-2006

Infection Protection (INFPRO)
Definition: Prevention and early detection of infection in a patient at risk.
Activities:
Monitor for systemic and localized signs and symptoms of infection
Monitor vulnerability to infection
Monitor absolute granulocyte count, WBC count, and differential results
Follow neutropenic precautions, as appropriate
Monitor others for communicable disease
Maintain asepsis for patient at risk
Maintain isolation techniques, as appropriate
Provide appropriate skin care to edematous areas
Inspect skin and mucous membranes for redness, extreme warmth, or drainage
Inspect condition of any surgical incision/wound
Obtain cultures, as needed
Promote sufficient nutritional intake
Encourage fluid intake, as appropriate
Encourage rest
Monitor for change in energy level/malaise
Encourage increased mobility and exercise, as appropriate
Encourage deep breathing and coughing, as appropriate
Administer an immunizing agent, as appropriate
Instruct patient to take antibiotics as prescribed
Teach the patient and family about signs and symptoms of infection and when to report them to
the
health care provider
Teach patient and family members how to avoid infections
Eliminate fresh fruits, vegetables, and pepper from the diet of patients with neutropenia
Remove fresh flowers and plants from patient areas, as appropriate
Report suspected infections
Background Readings:
Degroot-Kosolcharoen, J., & Jones, J.M. (1989). Permeability of latex and vinyl gloves to water and
blood.
American Journal of Infection Control, 17, 196-201.
Ehrenkranz, J.J., Eckert, D.G., & Phillips, P.M. (1989). Sporadic bacteremia complicating central venous
catheter use in a community hospital. American Journal of Infection Control, 17(2), 69-76.
Larsen, E., Mayur, K., & Laughon, B.A. (1989). Influence of two handwashing frequencies on reduction
in
colonizing flora with three handwashing products used by health care personnel. American Journal of
Infection Control, 17(2), 83-88.
339

Pottinger, J., Burns, S., & Manske, C. (1989). Bacterial carriage by artificial versus natural nails.
American
Journal of Infection Control, 17, 340-344.
Pugliese, G., & Lampinen, T. (1989). Prevention of human immunodeficiency virus infection: Our
responsibilities as health care professionals. American Journal of Infection Control, 17(1), 1-22.
Thompson, J.M., McFarland, G.K., Hirsch, J.E., & Tucker, S.M. (1998). Mosby’s clinical nursing (4th
ed.). St.
Louis: Mosby.

NIC Definition & Activities Page 37 9-2006

Medication Administration (MEDADM)
Definition: Preparing, giving, and evaluating the effectiveness of prescription and
nonprescription drugs.
Activities:
Develop agency policies and procedures for accurate and safe administration of medications
Develop and use an environment that maximizes safe and efficient administration of medications
Follow the five rights of medication administration
Verify the prescription or medication order before administering the drug
Monitor for possible medication allergies, interactions, and contraindications
Note patient’s allergies before delivery of each medication and hold medications, as appropriate
Ensure that hypnotics, narcotics, and antibiotics are either discontinued or reordered on their
renewal
date
Note expiration date on medication container
Prepare medications using appropriate equipment and techniques for the drug administration
modality
Restrict administration of medications not properly labeled
Dispose of unused or expired drugs, according to agency guidelines
Monitor vital signs and laboratory values before medication administration, as appropriate
Assist patient in taking medication
Give medication using appropriate technique and route
Use orders, agency policies, and procedures to guide appropriate method of medication
administration
Instruct patient and family about expected actions and adverse effects of the medication
Monitor patient to determine need for PRN medications, as appropriate
Monitor patient for the therapeutic effect of the medication
Monitor patient for adverse effects, toxicity, and interactions of the administered medications
Sign out and store narcotics and other restricted drugs, according to agency protocol
Verify all questioned medication orders with the appropriate health care personnel
Document medication administration and patient responsiveness, according to agency protocol
Background Readings:
Deglin, J.H., & Vallerand, A.H. (2001). Davis’s drug guide for nurses (7th ed.). Philadelphia: F.A. Davis
Co.
Lehne, R.A. (2001). Pharmacology for nursing care (4th ed.). Philadelphia: Saunders.
Naegle, M.A. (1999). Medication management. In G.M. Bulechek & J.C. McCloskey (Eds.), Nursing
interventions: Effective nursing treatments (3rd ed.) (pp. 234-242). Philadelphia: W.B. Saunders.
Perry, A.G., & Potter, P.A. (2002). Clinical nursing skills & techniques (5th ed.) (pp. 435-557). St. Louis:
Mosby.
340

Strome, T., & Howell, T. (1991). How antipsychotics affect the elderly. American Journal of Nursing,
91(5),
46-49.

NIC Definition & Activities Page 38 9-2006

Medication Management (MEDMGT)
Definition: Facilitation of safe and effective use of prescription and over-the-counter drugs.
Activities:
Determine what drugs are needed, and administer according to prescriptive authority and/or protocol
Discuss financial concerns related to medication regimen
Determine patient’s ability to self-medicate, as appropriate
Monitor effectiveness of the medication administration modality
Monitor patient for the therapeutic effect of the medication
Monitor for signs and symptoms of drug toxicity
Monitor for adverse effects of the drug
Monitor for nontherapeutic drug interactions
Review periodically with the patient and/or family types and amounts of medications taken
Discard old, discontinued, or contraindicated medications, as appropriate
Facilitate changes in medication with physician, as appropriate
Monitor for response to changes in medication regimen, as appropriate
Determine the patient’s knowledge about medication
Monitor adherence with medication regimen
Determine factors that may preclude the patient from taking drugs as prescribed
Develop strategies with the patient to enhance compliance with prescribed medication regimen
Consult with other health care professionals to minimize the number of drugs and frequency of doses
needed
for a therapeutic effect
Teach patient and/or family members the method of drug administration, as appropriate
Teach patient and/or family members the expected action and side effects of the medication
Provide patient and family members with written and illustrated information to enhance selfadministration of
medications, as appropriate
Develop strategies to manage side effects of drugs
Obtain physician order for patient self-medication, as appropriate
Establish a protocol for the storage, restocking, and monitoring of medications left at the bedside for
selfmedication
purposes
Investigate possible financial resources for acquisition of prescribed drugs, as appropriate
Determine impact of medication use on patient’s lifestyle
Provide alternatives for timing and modality of self-administered medications to minimize lifestyle effects
Assist the patient and family members in making necessary lifestyle adjustments associated with certain
medications, as appropriate
Instruct patient when to seek medical attention
Identify types and amounts of over-the-counter drugs used
Provide information about the use of over-the-counter drugs and how they may influence the existing
condition
Determine whether the patient is using culturally based home health remedies and the possible effects on
use
of over-the-counter and prescribed medications
Review with the patient strategies for managing medication regimen
Provide patient with a list of resources to contact for further information about the medication regimen
341

Contact patient and family after discharge, as appropriate, to answer questions and discuss concerns
associated
with the medication regimen
Encourage the patient to have screening tests to determine medication effects
Background Readings:
Le Sage, J. (1991). Polypharmacy in geriatric patients. Nursing Clinics of North America, 26(2), 273-290.
Malseed, R.T. (1990). Pharmacology drug therapy and nursing considerations (3rd ed.). Philadelphia: J.B. Lippincott.
Mathewson, M.J. (1986). Pharmacotherapeutics: A nursing approach. Philadelphia: F.A. Davis.
Weitzel, E.A. (1992). Medication management. In G.M. Bulechek & J.C. McCloskey (Eds.), Nursing interventions: Essential nursing treatments
(2nd
ed.) (pp. 213-220). Philadelphia: W.B. Saunders.

NIC Definition & Activities Page 39 9-2006

Multidisciplinary Care Conference (CONFILL and CONFINJ)
Definition1: Planning and evaluating patient care with health professionals from other
disciplines as related to illness or injury.
Multidisciplinary Care Conference (illness) CONFILL
Multidisciplinary Care Conference (injury) CONFINJ
Activities:
Summarize health status data pertinent to patient care planning
Identify current nursing diagnoses
Describe nursing interventions being implemented
Describe patient and family responses to nursing interventions
Seek input about effectiveness of nursing interventions
Discuss progress toward goals
Revise patient care plan, as necessary
Solicit input for patient care planning
Establish mutually agreeable goals
Review discharge plans
Discuss referrals, as appropriate
Recommend changes in treatment plan, as necessary
Provide data to facilitate evaluation of patient care plan
Clarify responsibilities related to implementation of patient care plan
Background Readings:
Mariano, C. (1989). The case for interdisciplinary collaboration. Nursing Outlook, 37(6), 285-288.
Richardson, A.T. (1986). Nurses interfacing with other members of the team. In D.A. England (Ed.),
Collaboration in nursing (pp. 163-185). Rockville, MD: Aspen.
1 Delaware

definition differentiates between intervention related to illness or injury.

NIC Definition & Activities Page 40 9-2006

Nausea Management (NAUSEA)
Definition: Prevention and alleviation of nausea.
Activities:
Encourage patient to monitor own nausea experience
Encourage patient to learn strategies for managing own nausea
Perform complete assessment of nausea including frequency, duration, severity, and precipitating factors,
using such tools as Self-Care Journal, Visual Analog Scales, Duke Descriptive Scales, and Rhodes Index
of Nausea and Vomiting (INV) Form 2
Observe for nonverbal cues of discomfort, especially for infants, children, and those unable to
communicate
effectively, such as individuals with Alzheimer’s disease
Evaluate past experiences with nausea (e.g., pregnancy and car sickness)
342

Obtain a complete pretreatment history
Obtain dietary history including the person’s likes dislikes and cultural food preferences
Evaluate the impact of nausea experience on quality of life (e.g., appetite, activity, job performance, role
responsibility, and sleep)
Identify factors (e.g., medication and procedures) that may cause or contribute to nausea
Ensure that effective antiemetic drugs are given to prevent nausea when possible (except for nausea
related to
pregnancy)
Control environmental factors that may evoke nausea (e.g., aversive smells, sound and unpleasant visual
stimulation)
Reduce or eliminate personal factors that precipitate or increase the nausea (anxiety, fear, fatigue and lack
of
knowledge)
Identify strategies that have been successful in relieving nausea
Demonstrate acceptance of nausea and collaborate with the patient when selecting a nausea control
strategy
Consider the cultural influence on nausea response while implementing intervention
Encourage not to tolerate nausea but to be assertive with health care providers in obtaining
pharmacological
and nonpharmacological relief
Teach the use of nonpharmacological techniques (e.g., biofeedback, hypnosis, relaxation, guided imagery,
music therapy, distraction, acupressure) to manage nausea
Encourage the use of nonpharmacological techniques before, during and after chemotherapy; before
nausea
occurs or increases; and along with other nausea control measures
Inform other health care professionals and family members of any nonpharmacological strategies being
used
by the nauseated person
Promote adequate rest and sleep to facilitate nausea relief
Use frequent oral hygiene to promote comfort, unless it stimulates nausea
Encourage eating small amounts of food that are appealing to the nauseated person
Instruct on high-carbohydrate and low-fat food, as appropriate
Give cold, clear liquid and odorless and colorless food, as appropriate
Monitor recorded intake for nutritional content and calories
Weigh patient regularly
Provide information about the nausea, such as causes of the nausea and how long it will last
Assist to seek and provide emotional support
Monitor effects of nausea management throughout

Background Readings:
Fessele, K.S. (1996). Managing the multiple causes of nausea and vomiting in the patient with cancer. Oncology Nursing Forum, 23(9), 14091417.
Grant, M. (1987). Nausea, vomiting, and anorexia. Seminars in Oncology Nursing, 3(4), 227-286.
Hogan, C., M. (1990). Advances in the management of nausea and vomiting. Nursing Clinics of North America, 25(2), 475-497.
Hablonski, R.S. (1993). Nausea: The forgotten symptom. Holistic Nursing Practice, 7(2), 64-72.
Larson, P., Halliburton, P., & Di Julio, J. (1993). Nausea, vomiting, and retching. In V. Carrier-Kohlman, A.M. Lindsey, & C.M. West (Eds.),
Pathophysiological phenomena in nursing human responses to illness. Philadelphia: W.B. Saunders Company.
Rhodes, V.A. (1990). Nausea, vomiting, and retching. Nursing Clinics of North America, 25(4), 885-900.

NIC Definition & Activities Page 41 9-2006

Neurologic Monitoring (NEURO)
Definition: Collection and analysis of patient data to prevent or minimize neurologic
complications.
Activities:
343

Monitor pupillary size, shape, symmetry, and reactivity
Monitor level of consciousness
Monitor level of orientation
Monitor trend of Glascow Coma Scale
Monitor recent memory, attention span, past memory, mood, affect, and behaviors
Monitor vital signs: temperature, blood pressure, pulse, and respirations
Monitor respiratory status: ABG levels, pulse oximetry, depth, pattern, rate, and effort
Monitor ICP and CPP
Monitor corneal reflex
Monitor cough and gag reflex
Monitor muscle tone, motor movement, gait, and proprioception
Monitor for pronator drift
Monitor grip strength
Monitor for tremor
Monitor facial symmetry
Monitor tongue protrusion
Monitor for tracking response
Monitor EOMs and gaze characteristics
Monitor for visual disturbance: diplopia, nystagmus, visual field cuts, blurred vision, and visual acuity
Note complaint of headache
Monitor speech characteristics: fluency, presence of aphasias, or word-finding difficulty
Monitor response to stimuli: verbal, tactile, and noxious
Monitor sharp/dull and hot/cold discrimination
Monitor for paresthesia: numbness and tingling
Monitor sense of smell
Monitor sweating patterns
Monitor Babinski response
Monitor for Cushing response
Monitor dressings for drainage
Monitor response to medications
Consult with co-workers to confirm data, as appropriate
Identify emerging patterns in data
Increase frequency of neurologic monitoring, as appropriate
Avoid activities that increase intracranial pressure
Space required nursing activities that increase intracranial pressure
Notify physician of change in patient’s condition
Institute emergency protocols, as needed

Background Readings:
Ackerman, L.L. (1992). Interventions related to neurological care. In G.M. Bulechek & J.C. McCloskey (Eds.), Symposium on Nursing
Interventions.
Nursing Clinics of North America, 27(2), 325-346.
Allan, D. (1986). Management of the head injured patient. Nursing Times, 82(25), 36-39.
Alspach, J.G. (Ed.). (1991). Core curriculum for critical care nursing (4th ed.). Philadelphia: W.B. Saunders.
Ammons, A.M. (1990). Cerebral injuries and intracranial hemorrhages as a result of trauma. Nursing Clinics of North America, 25(1), 23-34.
Cammermeyer, M., & Appeldorn, C. (Eds.). (1990). Core curriculum for neuroscience nursing (3rd ed.) (pp. Val-Val8 & Vbl-Vb5). Chicago:
American
Association of Neuroscience Nurses.
Crosby, L., & Parsons, L.C. (1989). Clinical neurologic assessment tool: Development and testing of an instrument to index neurologic status.
Heart &
Lung, 18(2), 121-125.
Hickey, J.V. (1992). The clinical practice of neurological and neurosurgical nursing (3rd ed.). Philadelphia: J.B. Lippincott.
Mitchell, P.H., & Ackerman, L.L. (1992). Secondary brain injury reduction. In G.M. Bulechek & J.C. McCloskey (Eds.), Nursing interventions:
Essential nursing treatments (2nd ed.) (pp. 558-573). Philadelphia: W.B. Saunders.
Price, M.B., & Vroom, H.L. (1985). A quick and easy guide to neurological assessment. Journal of Neurosurgical Nursing, 17(5), 313-320.
Titler, M.G. (1992). Interventions related to surveillance. In G.M. Bulechek & J.C. McCloskey (Eds.), Symposium on Nursing Interventions.
Nursing
Clinics of North America, 27(2), 495-516.

NIC Definition & Activities Page 42 9-2006

Non-Nursing Intervention (NONNURSE)
344

Definition: Providing service not required nursing skills/expertise.
NIC Definition & Activities Page 43 9-2006

Nursing Assessment, No Intervention (NASS)
Definition: Providing assessment requiring professional nursing knowledge and skills
without
related intervention.
NIC Definition & Activities Page 44 9-2006

Nursing Intervention (NURSE)
Definition1: Intervention requiring professional nursing knowledge and skills (not available
on
current Delaware NIC list).
1 Delaware

definition.

NIC Definition & Activities Page 45 9-2006

Nutrition Management (NUTMGT)
Definition: Assisting with or providing a balanced dietary intake of foods and fluids.
Activities:
Inquire if patient has any food allergies
Ascertain patient’s food preferences
Determine, in collaboration with dietician as appropriate, number of calories and type of
nutrients
needed to meet nutrition requirements
Encourage calorie intake appropriate for body type and lifestyle
Encourage increased intake of protein, iron, and vitamin C, as appropriate
Offer snacks (e.g.; frequent drinks, fresh fruits/fruit juice), as appropriate
Give light, pureed, and bland foods, as appropriate
Provide a sugar substitute, as appropriate
Ensure that diet includes foods high in fiber content to prevent constipation
Offer herbs and spices as an alternative to salt
Provide patient with high-protein, high-calorie, nutritious finger foods and drinks that can be
readily
consumed, as appropriate
Provide food selection
Adjust diet to patient’s lifestyle, as appropriate
Teach patient how to keep a food diary, as needed
Monitor recorded intake for nutritional content and calories
Weigh patient at appropriate intervals
Encourage patient to wear properly fitted dentures and/or obtain dental care
Provide appropriate information about nutritional needs and how to meet them
Encourage safe food preparation and preservation techniques
Determine patient’s ability to meet nutritional needs
Assist patient in receiving help from appropriate community nutritional programs, as needed.
Background Readings:
Mahan, L.K. (1996). Krause’s food nutrition and diet therapy (pp. 403-423). Philadelphia: Saunders.
Thelan, L.A. and Urden, L.D. (1998). Critical care nursing: Diagnosis and management (3 rd ed.). St.
Louis:
Mosby – Year Book.
345

Whitney, E.N. & Cataldo, C.B. (1991). Understanding normal and clinical nutrition (3 rd ed.). St. Paul,
MN:
West Publishing.

NIC Definition & Activities Page 46 9-2006

Nutrition, Special Diet (SPDIET)
Definition1: Modification and monitoring of special diet.
Activities:
Inquire if patient has any food allergies
Ascertain patient’s food preferences
Determine, in collaboration with dietician as appropriate, number of calories and type of
nutrients
needed to meet nutrition requirements
Encourage calorie intake appropriate for body type and lifestyle
Encourage increased intake of protein, iron and vitamin C, as appropriate
Offer snacks (e.g., frequent drinks, fresh fruits/fruit juice), as appropriate
Give light, pureed and bland foods, as appropriate
Provide a sugar substitute, as appropriate
Ensure that diet includes foods high in fiber content to prevent constipation
Provide patient with high-protein, high-calorie, nutritious finger foods and drinks that can be
readily
consumed, as appropriate
Provide food selection, as appropriate
Teach patient how to keep a food diary, as needed
Monitor recorded intake for nutritional content and calories
Weigh patient at appropriate or specified intervals
Provide appropriate information about nutritional needs and how to meet them
Encourage safe food preparation and preservation techniques
Determine patient’s ability to meet nutritional needs
Assist patient in receiving help from appropriate community nutritional programs, as needed
Monitor trends in weight loss and gain
Monitor type and amount of usual exercise
Monitor environment where eating occurs
Schedule treatment and procedures at times other than feeding times
Monitor for symptoms of inadequate nutritional intake
Monitor growth and development
Determine whether the patient needs a special diet
Background Readings:
Mahan, L.K. (1996). Krause’s food nutrition and diet therapy (pp. 403-423). Philadelphia: Saunders.
Thelan, L.A. and Urden, L.D. (1998). Critical care nursing: Diagnosis and management (3 rd ed.). St.
Louis:
Mosby – Year Book.
Whitney, E.N. & Cataldo, C.B. (1991). Understanding normal and clinical nutrition (3 rd ed.). St. Paul,
MN:
West Publishing.
1 Delaware

definition incorporates aspects of NIC’s “Nutrition Management” and “Nutrition Limiting.”

NIC Definition & Activities Page 47 9-2006

Ostomy Care (OSTO)
346

Definition: Maintenance of elimination through a stoma and care of surrounding tissue.
Activities:
Instruct patient/family in the use of ostomy equipment/care
Have patient/significant other demonstrate use of equipment
Assist patient in obtaining needed equipment
Apply appropriately fitting ostomy appliance, as needed
Monitor for incision/stoma healing
Monitor for postop complications, such as intestinal obstruction, paralytic ileus, anastomotic
leaks,
mucocutaneous separation, as appropriate
Monitor stoma/surrounding tissue healing and adaptation to ostomy equipment
Change/empty ostomy bag, as appropriate
Irrigate ostomy, as appropriate
Assist patient in providing self-care
Encourage patient/significant other to express feelings and concerns about changes in body
image
Explore patient’s care of ostomy
Explain to the patient what the ostomy care will mean to his/her day-to-day routine
Assist patient to plan time for care routine
Instruct patient how to monitor for complications (e.g., mechanical breakdown, chemical
breakdown,
rash, leaks, dehydration, infection)
Instruct patient on mechanisms to reduce odor
Monitor elimination patterns
Assist patient to identify factors that affect elimination pattern
Instruct patient/significant other in appropriate diet and expected changes in elimination function
Provide support and assistance while patient develops skill in caring for stoma/surrounding tissue
Teach patient to chew thoroughly, avoid foods that caused digestive upset in the past, add new
foods
one at a time, and drink plenty of fluids
Discuss concerns about sexual functioning, as appropriate
Encourage visitation by persons from support group who have same condition
Express confidence that patient can resume normal life with ostomy
Encourage participation in ostomy support groups after discharge
Background Readings:
Bradley, M., & Pupiales, M. (1997). Essential elements of ostomy care. American Journal of Nursing,
97(7),
38-46.
Craven, R.F., & Hirnle, C.J. (2000) Fundamentals of nursing: Human health and function (3rd ed.) (pp.
11091112). Philadelphia: Lippincott.
Innes, B.S. (1986). Meeting bowel elimination needs. In K.C. Sorenson & J. Luckmann (Eds.), Basic
nursing
(pp. 827-851). Philadelphia: W.B. Saunders.
O’Shea, H.S. (2001). Teaching the adult ostomy patient. Journal of Wound Ostomy and Continence
Nurses
Society, 28(1), 47-54.
347

NIC Definition & Activities Page 48 9-2006

Pain Management (PAIN)
Definition: Alleviation of pain or a reduction in pain to a level of comfort that is acceptable to the
patient.
Activities:
Perform a comprehensive assessment of pain to include location, characteristics, onset/duration, frequency, quality, intensity or severity
of
pain, and precipitating factors
Observe for nonverbal cues of discomfort, especially in those unable to communicate effectively
Ensure that patient receives attentive analgesic care
Use therapeutic communication strategies to acknowledge the pain experience & convey acceptance of the patient’s response to pain
Explore patient’s knowledge and beliefs about pain
Consider cultural influences on pain response
Determine the impact of the pain experience on quality of life (e.g., sleep, appetite, activity, cognition, mood, relationships, performance
of job,
and role responsibilities)
Explore with patient factors that relieve/worsen pain
Evaluate past experiences with pain to include individual or family history of chronic pain or resulting disability, as appropriate
Evaluate, with the patient and the health care team, the effectiveness of past pain control measures that have been used
Assist patient and family to seek and obtain support
Utilize a developmentally appropriate assessment method that allows for monitoring of change in pain and that will assist in identifying
actual
and potential precipitating factors (e.g., flow sheet, daily diary)
Determine the needed frequency of making an assessment of patient comfort and implement monitoring plan
Provide information about the pain, such as causes of the pain, how long it will last, and anticipated discomforts from procedures
Control environmental factors that may influence the patient’s response to discomfort (e.g., room temperature, lighting, noise)
Reduce or eliminate factors that precipitate or increase the pain experience (e.g., fear, fatigue, monotony, and lack of knowledge)
Consider the patient’s willingness to participate, ability to participate, preference, support of significant others for method, and
contraindications when selecting a pain relief strategy
Select & implement a variety of measures (e.g., pharmacological, nonpharmacological, interpersonal) to facilitate pain relief, as
appropriate
Teach principles of pain management
Consider type and source of pain when selecting pain relief strategy
Encourage patient to monitor own pain and to intervene appropriately
Teach the use of nonpharmacological techniques (e.g., biofeedback, TENS, hypnosis, relaxation, guided imagery, music therapy,
distraction,
play therapy, activity therapy, acupressure, hot/cold application, and massage) before, after, and, if possible, during painful activities;
before pain occurs or increases; and along with other pain relief measures
Explore patient’s current use of pharmacological methods of pain relief
Teach about pharmacological methods of pain relief
Encourage patient to use adequate pain medication
Collaborate with the patient, significant other, and other health professionals to select and implement nonpharmacological pain relief
measures,
as appropriate
Provide the person optimal pain relief with prescribed analgesics
Implement the use of patient-controlled analgesia (PCA), if appropriate
Use pain control measures before pain becomes severe
Verify level of discomfort with patient, note changes in the medical record, inform other health professionals working with the patient
Evaluate the effectiveness of the pain control measures used through ongoing assessment of the pain experience
Institute and modify pain control measures on the basis of the patient’s response
Promote adequate rest/sleep to facilitate pain relief
Encourage patient to discuss his/her pain experience, as appropriate
Notify physician if measures are unsuccessful or if current complaint is a significant change from patient’s past experience of pain
Inform other health care professionals/family members of nonpharmacological strategies being used by the patient to encourage
preventive
approaches to pain management
Utilize a multidisciplinary approach to pain management, when appropriate
Consider referrals for patient, family, and significant others to support groups, and other resources, as appropriate
Provide accurate information to promote family’s knowledge of and response to the pain experience
Incorporate the family in the pain relief modality, if possible
Monitor patient satisfaction with pain management at specified intervals

Background Readings:
Acute Pain Management Guideline Panel. (1992). Acute pain management: Operative or medical procedures and trauma. Clinical practice guideline. AHCPR Pub. No.
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