Texas School Nurse Program - Nursing Practice Resources

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Nursing Practice Resources page provides what’s happening in nursing practice including resources, regulations, laws or other requirements of the practice and profession of nursing with a focus on the school setting through the following publication, communication pathways and Frequently Asked Questions:

 

 

  • A Teacher's Guide to Galactosemia
  • Sickle Cell Disease: A Resource for the Educator
  • Methicillin Resistant Staphylococcus aureus (MRSA): The latest prevention and containment information, reporting and management recommendations, training materials and educational materials on MRSA for schools, athletes and correctional facilities.
  • Asthma Communications Toolkit: The purpose of this Asthma Communications Kit is to provide school leaders with a one-stop online resource to obtain information, forms and templates to communicate about asthma management in schools with staff, parents, the community and the media.  It was created by American Association of School Administrators and the National School Boards Association with support from with the Centers for Disease Control and Prevention, Division of Adolescent and School Health.  This toolkit is available to members and non-members alike.
  • Resources for Teachers of Students with special Health Needs:  Many teachers in Texas have students in their classrooms with unique health needs that require special attention or treatment. H.B. 1322 from the 81st Legislative session established a Web page on TEA's Web site to provide resources for teachers of students with special health needs.  The Web page provides teachers with access to information on the treatment and management of a variety of student health conditions, as well as information on the impact that such conditions may have on a student's well-being and academic success.
  • January 2009 School Nurse Update PowerPoint John Gemar’s PowerPoint presentation during the January 2009 School Nurse Update is now available for download.
  • Diabetes 101 - Excerpts from:  Helping the Child With Diabetes Succeed:  A Guide for School Personnel; a project of the National Institutes of Health and the Centers for Disease Control and Prevention, June 2003 Diabetes 101 (79k)
  • - Excerpts from:  a project of the National Institutes of Health and the Centers for Disease Control and Prevention, June 2003 (79k)

 

Frequently Asked Questions

Answered by the School Nurse Consultant

School Nursing General

Q. How many school nurses practice in Texas?
Q. Are school nurses required in Texas?
Q. How many schools in Texas employ nurses?
Q. What is the ratio of school nurses to students in Texas?
Q. How do Texas schools address health services delivery if nurses are not required?
Q: What do school nurses actually do?

Health Service Delivery

Q: What are the legal parameters for practice for credentialed medical assistive personnel in schools such as respiratory therapists, medical assistants, and EMTs?
Q: What should a school nurse do if a student arrives at school with no doctor's orders and the parent requests services?
Q: HELP!  What should a school nurse do if the health needs of one child do not allow the school nurse to carry out all other job responsibilities?
Q: Could you please explain specifically what "supervision" of an LVN means?
Q: What follow-up must a school nurse do for students whose parents submit conscientious or religious exemption affidavits for immunizations, screening exams and health education?
Q. What if a student with a conscientious or religious exemption is involved in a medical emergency during school?

School Nurse Administration of Medication

Q: What should the school nurse do regarding preparing medications for field trips?
Q. Must the school nurse accompany students on field trips that are known to experience anaphylactic reactions?
Q. Can a school nurse administer performance enhancing compounds containing a stimulant, amino acid or hormone precursor to students?  Can other staff do so?
Q. Can a school nurse administer sample medication to students?
Q. Can a school nurse administer herbals, home remedies or dietary supplements to students?
Q. Can a school nurse administer placebos for the management of pain?
Q.  Does the Nurse Practice Act preclude nurses from administering herbals and dietary supplements even with the TASB policy that makes an exception for students with this written into the IEP or 504 modifications?
Q: If a school nurse gives soda or cough drops to an ill student, has she violated the Texas Department of Agriculture Foods of Minimal Nutritional Value Policy?
Q: Can schools accept physician orders received via email?
Q. Can a school accept out-of-state physician orders?
Q: Can school nurses participate in medication studies in which unlabeled bottles are used?

Miscellaneous

Q: What is Acanthosis Nigricans screening?
Q: Are schools required to provide soap in the student restrooms?
Q: What can be done to help student(s) with reoccurring head lice?
Q: Can school personnel fax reports of suspected child abuse or neglect instead of calling the hotline?
Q: What is the status of the hepatitis A requirement for students in Texas schools?
Q: Are there recommendations regarding animals/pets in the classroom?

School Nursing General

Q. How many school nurses practice in Texas?
A.  The Texas Department of State Health Services School Health staff provides technical assistance and consultation to schools regarding school health staffing, programming and service delivery.  DSHS does not collect statistical data regarding RN and/or LVN employment, however, the Texas Board of Nursing does.  Please see their website at:
www.bon.state.tx.us.  Here, you will be able to retrieve information regarding RN practice by "field.”  School health is combined with college health, however, so the total number of "school nurses" is actually less than the total for this category.  LVN data is also available at this site.

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Q. Are school nurses required in Texas?
A.  There is no statutory requirement for Texas schools to employ a nurse except as indicated in Federal Individuals with Disabilities Education Act, but if the school DOES, it must comply with this section of the Texas Education Code:
§ 21.003.  CERTIFICATION REQUIRED.
(a) A person may not be employed as a teacher, teacher intern or teacher trainee, librarian, educational aide, administrator, or counselor by a school district unless the person holds an appropriate certificate or permit issued as provided by Subchapter B.
(b) A person may not be employed by a school district as an audiologist, occupational therapist, physical therapist, physician, nurse, school psychologist, associate school psychologist, social worker, or speech language pathologist unless the person is licensed by the state agency that licenses that profession. A person may perform specific services within those professions for a school district only if the person holds the appropriate credential from the appropriate state agency.

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Q. How many schools in Texas employ nurses?
A.  Data collected by the Texas Department of State Health Services through school district surveys in 2001 indicate that approximately 72% of Texas schools have a school nurse available to students at least part of the time. However, current data is not available to DSHS at this time.

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Q. What is the ratio of school nurses to students in Texas?
A.  The Texas Department of State Health Services utilizes data from the Board of Nursing, in which RNs self-report as being employed in either school or college health, compared to the number of public school children in the state for the 2012-2013 school years (
5,075,840), the ratio would appear to be 676 students per school nurse.  However, remember that the RNs include "college" health and the student count used above includes only public schools.  Hence this ratio is not accurate, but is an estimate.  The Higher Education Coordinating Board for Texas has data on the number of students enrolled in higher education institutions.  They can be reached via telephone at: 512-427-6101 or through their Web site at www.thecb.state.tx.us.

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Q. How do Texas schools address health services delivery if nurses are not required?
A.  Texas law now requires local school health advisory councils to consider all eight components of coordinated school health when advising local boards of trustees.  See Texas Education Code section 28.004 at this link:
http://www.statutes.legis.state.tx.us/Docs/ED/htm/ED.28.htm#28.004.  The recommendations of the school health advisory council go to the school board of trustees and have the potential to improve all aspects of school health related staffing and programming.  When nurses are not available to provide health services to students, this responsibility is assigned by the school principal to other staff, usually office staff or other paraprofessionals.  Some districts include health services delivery as a responsibility of teachers.

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Q: What do school nurses actually do?
A.  School nurses are licensed health care professionals who play a vital and challenging role in schools today.  They have received a thorough education and rigorous training, and are "real nurses” just like those employed by hospitals, doctor's offices, home health agencies, etc.  Although certification regulations vary by state, the National Association of School Nurses recommends that school nurses have a bachelor's degree and be a registered nurse.  The Texas Board of Nursing believes that school nursing is a professional registered nursing specialty.  Texas Education Agency rules for salary determination define "school nurse" as a registered nurse; however, school districts in Texas are under no legal requirement to hire RNs or licensed vocational nurses, so the person in the nurse's office might not actually be a nurse!  If that is the case, the unlicensed person should not use the title "nurse" as this is a protected title under Texas law.

 

The job of the school nurse has grown and expanded considerably over the years.  In addition to performing vision, hearing and spinal screening, school nurses provide care to students with chronic illnesses, such as asthma, seizure disorders and diabetes, which require special care during the school day.  The school nurse administers medication to students, performs special procedures and provides extended first aid and care for those children with minor injuries or illness during the school day.  In any given day the school nurse may see as many as 50-100 or more students and must also have the professional judgment and skills necessary to:

  • assess lung sounds of an asthmatic student and provide a nebulizer treatment if indicated;
  • communicate with parents, teachers, or physicians regarding the effectiveness of medication for a student with Attention Deficit/Hyperactivity Disorder;
  • care for a child with a seizure;
  • perform a complex treatment for a child with special health care needs, such as suctioning a tracheostomy or administering medication via a feeding tube or intravenous port;
  • respond to a school related emergency, such as a playground accident, a school bus accident or some other critical incident that affects the health and safety of students or staff;
  • attend a parent conference, 504 Committee meeting or Admission, Review and Dismissal meeting if student health concerns are affecting learning;
  • provide supplemental classroom instruction and materials on various health related topics;
  • provide one-on-one health counseling to individual students;
  • serve as a resource for families in need of support through community or social agencies or programs;
  • be confident and prepared to handle every health related incident that may occur.

 

In addition to performing a broad range of health functions, the school nurse communicates with parents, school staff, public health agencies and physicians’ offices regarding communicable disease outbreaks and other health concerns.  The school nurse is often called upon to advise school administrators in formulating health policies or protocols.  He or she may also plan and implement school wide health education campaigns or activities such as health fairs or special health observance days.  The school nurse may give presentations to parent or community groups.

The school nurse is also responsible for organizing and maintaining the health related documents, such as immunization records and health information forms for each student.  It is vital that the school nurse know where parents or other caregivers can be reached during the day in case of an emergency.  The nurse should also know the name of the child's pediatrician, which local hospital parents prefer the child be taken to if the parent can't be reached, and, if school policy allows, whether or not the child can be given certain medications, such as acetaminophen for high fever.

 

Parents are always welcome volunteers in schools and this provides an opportunity to become familiar with how the school operates.  Parents are often needed on committees, such as campus improvement teams or district health advisory councils.  Parents should get to know the person responsible for the health program in the district and find out the experience and qualifications of the staff that provide health service delivery.  Essentially the partnership of school nurse, parents and physicians is key to a successful school year, especially if a child has special health needs.

 

Most importantly, the school nurse is a child advocate familiar with the complicated institutions of both education and healthcare.  As a member of the educational team the school nurse can help parents navigate through the school system successfully.

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Health Service Delivery

Q: What are the legal parameters for practice for credentialed medical assistive personnel in schools such as respiratory therapists, medical assistants, and EMTs?
A.  It is difficult to respond in general because one size does not necessarily fit all.  The first step here is to become familiar with the practice laws for the specific practitioner.  They can usually be found on the internet by doing a search.  You will need to specify the state of Texas because there may be differences from state to state.  For most of these practitioners, there is a restriction to practice only under the direction of a "qualified medical director or other physician licensed by the Texas State Board of Medical Examiners."  So in the school setting, a medical assistant should be considered a lay person, unless you have a physician to supervise and delegate tasks according to the Medical Practice Act.  Practitioners should be considered unlicensed assistive personnel ... a very knowledgeable UAP, but nonetheless, an unlicensed person in the school setting.  They would need to follow the same protocols and procedures set forth for lay persons assisting with health services, which includes the registered nurse assessing the UAP’s level of knowledge and skill.  If you have additional questions, you can contact the Texas Department of State Health Services Professional Licensing and Certification Unit at
licensing@dshs.state.tx.us  or visit their web site at www.dshs.state.tx.us/plc/default.shtm.  DSHS recognizes the various care providers in schools and has developed a document, School Health Services Staff Roles, to assist in determining roles and responsibilities in the delivery of health services in the school setting.  This document was developed with input from the Board of Nursing and the state School Health Advisory Committee.  It has since been revised and adopted by the Texas School Health Advisory Committee and can be accessed at: http://www.dshs.state.tx.us/schoolhealth/schnurs.shtm

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Q: What should a school nurse do if a student arrives at school with no doctor's orders and the parent requests services?
A.  Under Texas law, medical treatments and/or medical procedures require a doctor's prescription or doctor's order.  When the requested service involved requires one of these, the school nurse should be firm with the parent about this requirement, and may NOT begin the services until the requirement for a prescription or doctor's order is met.  Communication with the Special Education Department or those who lead Admission, Review and Dismissal meetings is absolutely necessary.  Parents want their child to be welcomed at school, and often interpret the nurse’s request for documentation to mean that he/she does not want to provide services to their child.  Communication and advance planning goes a long way in assuring that everyone’s roles and responsibilities are understood.  School staff doesn’t want to be caught unaware, or experience an adverse event, in which they are not prepared with the information, equipment or staff needed to respond to a student’s health condition.  Parents are encouraged to begin communicating with the school nurse as soon as they know that their child may need health related services.  If you are the parent of a student served by special education, ask if the nurse has been included in planning for your child.  If you are a school employee, make sure that you have communicated with other staff as well as the parent.

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Q: HELP!  What should a school nurse do if the health needs of one child do not allow the school nurse to carry out all other job responsibilities?
A.  The first step is for the nurse to make his/her immediate supervisor aware of the problem by notifying the supervisor in writing and suggesting that an Admission, Review and Dismissal meeting or brief staff meeting be convened to remedy the situation.  By informing the supervisor, the nurse goes on record as having informed someone in a position to address the problem.  Next, wait a reasonable amount of time for a response.  If no response is forthcoming, the nurse should consider filing a formal grievance to resolve the issue, utilizing the procedures adopted by the school district for filing grievances.
If the problem rises to the level of substantially interfering with a nurse's ability to provide competent care to all students, then the nurse should notify the person who receives the Level 1 grievance that his/her intent is to contact the Texas Education Agency and/or Texas Board of Nursing if the issue is not resolved at the first level of the grievance process.

 

See also BON Rule 217.11 regarding Peer Review - Safe Harbor.  Some schools have hired additional staff and some have worked with parents to make care arrangements such as a private duty nurse, or a home health nurse.  Any such arrangement should be reviewed by the district’s legal counsel and documented in the form of a memorandum of understanding or other type of agreement.

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Q: Could you please explain specifically what "supervision" of an LVN means?
A.  Direct supervision requires a registered professional nurse to be immediately available to coordinate, direct, and observe firsthand another individual for whom the RN is responsible.  The RN must provide adequate supervision for those whom the RN is administratively responsible.  Supervision is non-specific because it is dependent on several factors.  The supervising RN must use professional judgment and the nursing process when determining the level of supervision.  The amount of supervision warranted will depend on the setting in which care is provided, the training, experience and capability of the individual being supervised, the needs of the clients being served, and the availability of the RN.  All licensed vocational nurses must have supervision by an RN or MD.  These guidelines can be found on the Board of Nursing’s Web site at: 
http://www.bon.state.tx.us/practice_scope_of_practice_lvn.asp

The Board of Nursing discusses the topic of supervision in Chapters of their Rules and Regulations, which can be found at www.bon.state.tx.us.

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Q: What follow-up must a school nurse do for students whose parents submit conscientious or religious exemption affidavits for immunizations, screening exams and health education?
A.  Honor the parental request, notify the campus and district level administration and consult with the district's legal counsel.  For information on conscientious objection requirements, go to
www.dshs.state.tx.us/immunize/school/default.shtm#exclusions.

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Q. What if a student with a conscientious or religious exemption is involved in a medical emergency during school?
A.  This question generates much discussion in EMS classes.  The response depends on the emergency, however all emergencies are not created equal!  The case is clearer if the parent has provided his/her wishes and expectations to the school nurse in writing and in advance.  If it is a minor injury or illness and contact with a parent can be made, the nurse should respect the parents' wishes.  If the nursing assessment reveals a life-threatening injury or illness and contact with a parent cannot be made and no written directive exists to the contrary, it is assumed the parent would want life sustaining care for the child.  EMS and law enforcement can be contacted via 911.  EMS would be required to render a full regimen of care unless there is a legally executed Out-of-Hospital DNR order on record for the student.  Once they arrive on the scene, they have protocols that may allow them to be granted emergency custody of the child.  This requires a court order from a judge.

 

Because EMS functions under a completely different set of laws than RNs and LVNS, it is advisable for the school nurse to seek legal counsel from the school district's attorney.
What course of action to take "in the meantime" while awaiting EMS arrival is another question?  The school district, with the assistance of legal counsel may choose to establish their policy regarding responses to student emergencies.  Does the policy state that all lifesaving efforts will be made for all students?  Does the policy state that the response will be handled on a case by case basis depending on what the parents have expressed in writing?  Does the district have staff and equipment to take action while awaiting EMS arrival?

 

EMS has a "buffer zone.”  They can call medical control and explain the situation to a physician who may advise them to transport the patient.  The decision then becomes a team effort and follows a sequential and legal process.  The decision is not one the school nurse or any school employee would want to make in isolation.

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School Nurse Administration of Medication

Q: What should the school nurse do regarding preparing medications for field trips?
A.  The Board of Nursing covers this issue in Chapter 225 of their Rules and Regulations, link provided here: 
www.bon.state.tx.us. The rules in this chapter apply to schools and include meter dose inhalers and pill box containers.  The RN may prepare the single dose container for the designated school employee to administer.  The employee should be trained by the nurse.  A documentation mechanism should be developed as well, to include in the student's medication administration record.  When reviewing Chapter 225 of the BON Rules and Regulations, see in particular Section 225.10.  Item number 11 in Section 225.10 specifically addresses this issue.

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Q. Must the school nurse accompany students on field trips that are known to experience anaphylactic reactions?
A.  If a student's Individualized Education Plan or 504 Plan states that certain procedures must be carried out by a nurse and those procedures will be needed during the field trip, then the school would have to make arrangements for a nurse to accompany the student or meet the student at some point during the field trip.  If there is no stipulation in this regard, or if the student does not have an IEP or 504 Plan, then there is no requirement for the nurse to accompany the student on the field trip.  Generally speaking, the administration of epi-pens is a procedure that can be carried out by adequately trained school personnel, or even self-administered by the student, as long as this has been agreed upon and planned for by the parents, physician, chief administrator and nurse.  For specific laws related to anaphylactic medications, go to: 
http://www.statutes.legis.state.tx.us/Docs/ED/htm/ED.38.htm#38.015

The Board of Nursing regulations state that nurses cannot delegate the administration of injectable medications to unlicensed staff (see Rule 225.12(B)).  However, BON Rule 224.6(4) would apply in emergency situations: "the nursing task must not require the unlicensed person to exercise professional nursing judgment; however, the unlicensed person may take any action that a reasonable, prudent non-health care professional would take in an emergency situation.”  For this reason, the chief administrators, working with the nurse, should create procedures for how emergent situations are handled when the nurse in not present.  The nurse plays a key role here in facilitating communication between the administrator and the staff so that all personnel are adequately trained and award of the expectations of them in cases of emergency.

 

Furthermore, the Texas Education Code allows for the chief administrator to assign the task of medicine administration to unlicensed staff (see section 22.052(a)).  This has been interpreted to include any medication, including injectables.  Under these circumstances, it becomes the responsibility of the nurse to work with the chief administrator to develop an emergency plan so that the staff designated to administer the medication are appropriately trained and prepared to handle the scenarios that may result.  The nurse must verify staff competency in carrying out the procedure, assure patient safety and inform the chief administrator if the task needs to be assigned to someone else (see BON Rule 225.13).  This in itself is not "delegation" by the nurse.  The chief administrator has assigned the task, and the nurse is ensuring that the people assigned the task are trained and prepared and that the student will receive the best possible care.

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Q. Can a school nurse administer performance enhancing compounds containing a stimulant, amino acid or hormone precursor to students?  Can other staff do so?
A.  Performance enhancing compounds and dietary supplements are not always herbals.  The law you are referring to can be found in the Texas Education Code.  An RN would not administer a substance that she is unfamiliar with, does not know the ingredients of, does not know the dosage of, drug interactions of, and for which there is not a body of supported research literature (medical, nursing, pharmacology).  However if it is in a student's Individual Education Plan as being necessary to their education, other school employees may make this accommodation, and in order to do so, the school may require written authorization from a physician.  Remember that the Individuals with Disabilities Education Act, found at
http://idea.ed.gov,  is federal law and the school is required to provide certain services to a student if those services are necessary for the student to receive a free and appropriate public education.  We recommend that school staff work with the parents and that all efforts are made for the student to receive the herbal or dietary supplement at home.  The RN has a responsibility to collaborate with other members of the health care team and to be a patient advocate.  The RN may use her professional judgment and in fact may decide to administer an herbal if he/she is familiar with the ingredients and is knowledgeable about the substances including their effects & interactions.  In addition, a body of medical and nursing research should exist supporting the use of the substance.  This research should show the substance to be safe and effective for the specific age group to whom it is to be administered.

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Q. Can a school nurse administer sample medication to students?
A.  Sample medication provided by a doctor can be administered by the RN when it is accompanied by a signed doctor's order for the medication and written permission from the child's parent or legal guardian.  School districts are allowed to adopt policies regarding the administering of sample medication.  It would be wise to check your district's policy or develop one.

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Q. Can a school nurse administer herbals, home remedies or dietary supplements to students?
A.  The RN is obligated to administer only those medications and treatments of which he/she is knowledgeable and for which there is a supporting body of research literature (See BON Rule 217.11(C)).  Therefore, the RN has the responsibility to refuse to administer medication which he/she believes is not in the best interest of the patient per Rule 217.11.  Further, the RN has the duty to clarify and question any unclear order (Rule 217.11(N)).  Since herbals, home remedies and dietary supplements do not generally come with a doctor's order, supporting body of research literature, known side effects, FDA approval, or a list of ingredients, the wise and prudent RN typically makes the decision not to administer them.  Furthermore, Texas law prohibits school district employees from selling, distributing, endorsing or suggesting performance enhancing substances.  Creatine is an example of such a substance.

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Q. Can a school nurse administer placebos for the management of pain?
A.  As published in The California Boards of Registered Nursing Report (Spring 1997), it is the CBRN's position that administration of a placebo for pain management does not meet the CBRN's intent of informed consent as stated within the CBRN's Pain Management Policy.  Placebos should only be given when administered as part of an approved research study where all patients are aware they may be receiving a placebo (written informed consent).  Use of placebos would breach the basic premise of pain management, which is that patients who report pain are entitled to the best possible treatment reflecting current research on methods that are safe and effective.
In Addition, the Minnesota Board of Nursing has addressed RN involvement in placebos:
Minnesota Nursing Practice Act: 148.261 Grounds for disciplinary action. "Knowingly providing false or misleading information that is directly related to the care of that patient unless done for an accepted therapeutic purpose such as the administration of a placebo."

 

Lastly, The American Society of Pain Management Nurses addresses the use of placebos as a mechanism to assess and manage pain and can found at www.aspmn.org and the American Nurses Association's Code of Ethics for Nurses may also address placebos.  While these organizations cited do not have regulatory authority over Texas licensure, they can be used as a guide during the decision making process.  RN's will want to explore resources, facility policy and procedure, and ethical standards to come to a safe and sound decision that is in the client's best interests.

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Q.  Does the Nurse Practice Act preclude nurses from administering herbals and dietary supplements even with the TASB policy that makes an exception for students with this written into the IEP or 504 modifications?
A.  The updates that each district receives from the Texas Association of School Boards are tailored to fit the policy that the district has previously.  Therefore, TASB sends out several different versions of each update (so what you and others are looking at may not all read the same).  The Texas Department of State Health Services assisted TASB with the language of this policy, but we do not advocate administering herbals and dietary supplements.  However, the TASB legal review team felt like this language should be included as a reminder of federal laws and obligations under the Individuals with Disabilities Education Act for special education students.  The likelihood of an herbal actually being written into an Individualized Education Plan is small, but does exist.  However, this doesn't state the RN must be the employee to administer it - it just reminds the district of their need to make accommodations according to a student's IEP.  TASB puts out recommendations, but districts are free to alter them, reject them or adopt them according to their local needs and preferences.  The school district attorney may not share the same opinion as TASB lawyers regarding the herbal IEP language.  When TASB policy staff was asked about this, the bottom line was that districts have the final say.

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Q: If a school nurse gives soda or cough drops to an ill student, has she violated the Texas Department of Agriculture Foods of Minimal Nutritional Value Policy?
A.  In principle TDA is not attempting to interfere with individual decisions made on a case by case basis involving the school nurse and ill students.  If the nurse decides that a student needs a cough drop, a peppermint, or needs to sit for a while and sip soda and eat crackers to settle an upset stomach, that would be okay.  For more information on this policy, see
www.agr.state.tx.us  or contact the TDA Food and Nutrition Division at 512-463-2076.  The Child Nutrition Program Specialist at your Education Service Center can also assist you with the implementation of this policy.

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Q: Can schools accept physician orders received via email?
A.  Both the Texas Board of Nursing and Board of Medical Examiners concur that school nurses should have a system in place to verify that the order originated from the physician.  An emailed order can be considered valid only if it contains an electronic copy of the physician's signature and the email address can be confirmed.  Without these criteria met, the email should be considered unacceptable due to authentication issues.  Some options in this case are 1) the physician's office can fax the order to the school with the physician's signature, 2) the nurse could contact the physician's office by phone to verify the order and 3) the parent and/or physician's office can deliver/mail a hardcopy of the order with the physician's signature.

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Q. Can a school accept out-of-state physician orders?
(The following response is provided by the Texas Board of Nursing…)
A.  Registered nurses in Texas may accept orders only from those physicians who are legally authorized to practice in this state.  The Medical Practice Act and related rules state that physicians practicing across state lines into Texas are required to have a special purpose license to practice medicine in this state (see Board of Medical Examiners Rule 174 Telemedicine).  This rule does provide exemptions to licensure (174.13) including situations such as (1) "episodic consultation" and (2) physicians located in states bordering Texas.  In relation to the later, this provision permits licensed home and community support services agencies in Texas to accept orders for home health or hospice services from physicians located in states bordering Texas.  In relation to school nursing, medication may be administered by the RN, as ordered by a physician who meets the aforementioned BME requirements, or the Education Code, section 22.052(a), permits principals to assign medication administration to school district employees.  Texas statutes, rules and regulations may be viewed on-line via the State of Texas website at
www.texas.gov.

For school RN's, it is acceptable to implement out-of-state physician's orders for children who recently moved to Texas and are in the process of establishing care with a Texas physician.  Such a practice should be a short-term solution.

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Q: Can school nurses participate in medication studies in which unlabeled bottles are used?
A.  The Texas State Board of Nursing has not addressed the RN's role in administering placebos, but several standards (Rule 217.11) apply:
(C)  knowing the rationale and effect of medications
(F)  promote client education
(N) clarifying orders
(P)  collaboration; and
Unprofessional Conduct Rule 217.12(H): "providing information which was false, deceptive, or misleading in connection with the practice of professional nursing."
The concern in a double blind study is that the RN would not know which medication he/she is administering.  The RN should have information about ALL the medications in the study that might be administered so that potential side effects and adverse drug reactions could be monitored.  Hence for RNs participating in a bona fide research, there are ways to administer placebos and still adhere to the above standards.  Certainly informed consent is a big factor.  The California Board of Registered Nursing has a position statement pertaining to this issue (see prior question on administering placebos).

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Miscellaneous

Q: What is Acanthosis Nigricans screening or what is now called Type 2 Diabetes Screening?
A.  Please go to
www.dshs.state.tx.us/schoolhealth/organscreen.shtm for an overview on Type 2 Diabetes screening in Texas schools. In addition, the following website will navigate to the Type 2 Diabetes Program at UT-Pan Am- Office of Boarder Health.  https://rfes.utpa.edu/

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Q: Are schools required to provide soap in the student restrooms?
A.  The Texas Department of State Health Services recommends that all school facilities have soap as well as hot and cold running water, towels and/or hand dryer available in all restrooms on a campus.  At this time there is not a legal requirement that schools provide these.  It is a recommendation.  However, a strong argument can be made to school officials that a lack of hand washing facilities/supplies will increase the incidence of communicable diseases among students and staff, thus increasing absentee rates significantly.  Proper and frequent hand washing is the single most effective method to prevent disease transmission.  It therefore makes sense for the health and welfare of students and staff to provide soap and hot running water.  As a deterrent to vandalism and potential accidents from slippery floors, emphasis can be placed on providing janitorial services to those problem bathrooms, more adult supervision, and prohibitive consequences for those students found to be vandalizing bathroom facilities.  Students should be encouraged to report messes in the bathroom to school staff so that they can be cleaned up before an accident occurs.  Health education concerning the importance of hand washing in preventing communicable diseases may also help instill a sense of pride and importance in the students' minds about the public restrooms.  One way to get your concerns heard is to share them with your district's school health advisory council.  For more information on SHACs, go to
www.dshs.state.tx.us/schoolhealth/sdhac.shtm.

 

Hand-sanitizing lotions readily available at stores and pharmacies can also be effective in cleaning hands if no water/soap is available.  You may want to have your child carry one of these with her or keep it in her locker if feasible to use when soap is not available in the restroom. 

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Q: What can be done to help student(s) with reoccurring head lice?
A.  It is important to ensure that the parents of the student have an understanding of what head lice are, how they are spread, and the recommended methods for treatment of both child, other members of the household, and their home environment.  This information and more is available on the Texas Department of State Health Services Head Lice Web site at
www.dshs.state.tx.us/schoolhealth/lice.shtm.

What may appear to be a reoccurrence of head lice may be the same initial infestation, which has not been treated properly.  It is important that parents follow the exact directions on the product they are using and follow through on the indicated treatment regimen.  Some of the treatments available are not 100% effective at killing head lice.  If the parent suspects the medication is not working, then they should seek the advice of a pharmacist or physician.  Changing to another product (with a different active ingredient) could have improved results.

 

If you suspect the parents are simply not devoting enough attention to treating the child’s head lice, this may be a sign of more serious problems in their household.  When possible, try to ascertain the bigger picture, and determine if there are any agencies or individuals in your community that can assist the family in addressing the larger issues that may be preventing the parents from devoting the energy and time necessary to treat their child’s head lice.  If you feel the child is being neglected and/or harmed, you should contact the Texas Child and Family Protective Services at 1-800-252-5400.

 

In terms of the effect of reoccurring head lice on a student’s attendance record, it is up to the school district to adhere locally developed policy.  DSHS no longer requires exclusion from school if live lice are present.  For more information on how to manage head lice in the school setting, please go to www.dshs.state.tx.us/schoolhealth/lice.shtm.

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Q: Can school personnel fax reports of suspected child abuse or neglect instead of calling the hotline?
A.  Texas Child and Family Protective Services do have a fax machine to receive written reports of abuse/neglect.  Incoming faxes on this line will be received and entered into a database by intake staff.  A specialist will then review the report.  It is possible that more than one staff person may come into contact with a report that has been faxed.  However, these are the same staff that has access to the computer and telephone reports, and one can assume that they have been trained to handle these reports in a professional manner so as not to violate confidentiality.
There are two optional fax numbers for sending in reports of abuse/neglect to the Texas Child and Family Protective Services are 1-800-647-7410 or 512-339-5900.

 

Texas Child and Family Protective Services states that if one wishes to ensure that as few staff persons as possible see a report, he or she should call the hotline at 1-800-252-5400.

 

The information needed to file a report (either by fax or phone) is 1) family name and location (address preferable), 2) the school/grade of the child(ren) whom the report concerns, and 3) what information do you have that leads you to suspect abuse / neglect?  For more info on reporting abuse/neglect, see the Texas Child and Family Protective Services web site at www.dfps.state.tx.us/Contact_Us/report_abuse.asp.

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Q: What is the status of the hepatitis A requirement for students in Texas schools?
A.  Children must show proof of two doses of hepatitis A vaccine if they are enrolled in a child-care center or attend Kindergarten through 3rd grade.  The child-care center requirement begins when a child is age 2.  For any other questions regarding this matter, please contact the Texas Department of State Health Services Immunization Division, 1100 W. 49th Street, Austin, TX 78756; 1-800-252-9152 or 512-458-7284.  Or visit the DSHS Immunization Division web site at
http://www.dshs.state.tx.us/immunize/school/default.shtm

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Q: Are there recommendations regarding animals/pets in the classroom?
A.  Some of the animals that would not be recommended include baby chicks and ducks (high risk for salmonellosis and campylobacteriosis); reptiles, such as snakes, lizards, turtles, and iguanas (high risk for salmonellosis); hedgehogs (risk for salmonellosis); any wild animals such as bats, skunks, raccoons, coyotes, and foxes (high risk for rabies, bites, and parasites); psittacine birds such as parrots, parakeets, budgies, and cockatiels (risk for psittacoss); and brushtail possums (risk for tuberculosis). Dogs and cats come with their own set of problems (high risk for bites, need specific vaccinations, can transmit zoonotic parasites...) plus they would require weekend maintenance.  Specific information relating to zoonotic diseases can be found on the Texas Department of State Health Services Zoonosis Control Division's web site at
www.dshs.state.tx.us/idcu/health/zoonosis/.  For additional info and recommendations, see the National Association of School Nurses position statement on animals in classrooms at www.nasn.org/Default.aspx?tabid=61

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Last updated June 05, 2014