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School Nurses: Putting the School Nurses: Putting the Pieces TogetherPieces Together
Florida Association of School Nurses 14th Annual Conference
February 6-7, 2009Orlando Marriott Lake Mary
Mental Health NursingMental Health Nursing
• Nursing Assessment and Care of Students with Mental Health Needs in a School
Setting
• Carole A. Kain, ARNP, PNP-BC, DNS (c)• Florida Atlantic University
What is mental health?What is mental health?
• It is not the absence of mental illness.• It is the successful performance of mental
function, that results in productive activities, fulfilling relationships with other people and the ability to adapt to change and cope with adversity.
What is mental illness or What is mental illness or disorder? disorder?
• Conditions that are characterized by alterations in mood, thinking or behavior that is associated with distress and/or impaired functioning.
Why the interest of mental health Why the interest of mental health in schoolsin schools
• 1995 Research demonstrates that“ As much as 80% of child mental health
services are delivered in the school setting”Barbara Burns et. al
“making schools the “default mental health system” for children in the US.
Julia Lear
Who else thinks mental health in Who else thinks mental health in schools is important? schools is important?
• 1999: Surgeon General Satcher states that mental health is fundamental to all health.
• “The burden of suffering experienced by children with mental health needs and their families has created a health crisis in this country”
David Satcher, MD, PhD
Surgeon General identifies Surgeon General identifies pediatric at risk patients.pediatric at risk patients.
• 2000The number of pediatric patients seen in primary
care who have a psychosocial problem increased from 7% to 19% in the last 20 years. 13% have anxiety disorders10% have a disruptive disorder 6% have mood disorders2% have a substance abuse disorder
National level reportsNational level reports
• 2003• President Bush argues that expanding mental health services in school was a keystep toward overcoming barriers to mental
health care. Report by: President’s New Freedom Commission on Mental Health
LetLet’’s look at the numberss look at the numbers
• 1,000 children in your school• 270 or approx. 27% have a mental health
impairment• 200 or approx. 20% have a diagnosable
mental health condition • 470 total
Why donWhy don’’t children get services?t children get services?
• Parents and others believe that child will “grow out of” the problem.
• Problem may reflect issues in family that parent is not ready to deal with
• Lack of insurance or funds to pay for care• Lack of parity in the insurance system
Role of the School Nurse in Role of the School Nurse in caring for students with mental caring for students with mental
health needshealth needs
• Specialized practice of professional nursing that advances the well-being , academic success and lifelong achievement of the student. • Intervene with actual or potential emotional or
behavioral concerns
Intervention achieved through:Intervention achieved through:
• 1:1 assessment and care• Family assessment and care• Advocacy for student in and out of school
system• Collaborate with other mental health care,
medical and nursing professionals
Using the Nursing ProcessUsing the Nursing Process in School Nursingin School Nursing
• Supported by NASN• Is the basis upon which critical decision making
is made.• Uses Nursing’s common language: NANDA
(North America Nursing Diagnosis Association), NIC ( Nursing Interventions Classification) and NOC ( Nursing Outcomes Classification)
The Nurse preparesThe Nurse prepares
• An Individualized Healthcare Plan.• Nurse decides who needs a plan• Should be based on the identification of “goals
of intervention” for an identified student problem
• Problem may be physical, emotional, behavioral
• Includes: Assessment, Nursing Diagnosis, Outcome Identification, Planning, Implementation, and Evaluation
WHY DO an IHP???WHY DO an IHP???
• To receive credit for the work you are doing!
Psychiatric Nursing AssessmentPsychiatric Nursing Assessment Data is gathered from multiple sources by Data is gathered from multiple sources by
multiple meansmultiple meansSources• Client• Family• Teachers• Record review
MethodsInterviewingDirect behavioral observationRecord review
past psychological testingpast developmental testing
Physical assessment
Standard I:Standard I: AssessmentAssessment
• Ability to be safe• Chief concern/
complaint• Physical, emotional
and cognitive status• Relatedness• Affect• Information
Processing
• Control • Self-efficacy• Organization• Past problems with
health/development• Daily activities• Interpersonal
relationships• Support systems
Standard IIStandard II: : Nursing DiagnosisNursing Diagnosis
• From NANDA• A conceptualization of the client’s response
from a unique nursing perspective• Not from DSM IV—these are medical
diagnosis and used by physicians, nurse practitioners, mental health professionals
Standard III : Standard III : Outcome IdentificationOutcome Identification
• What is Ultimate Goal? • Should be client centered, realistic, attainable• Cost-effective • Measureable• Be evidence based and therapeutically sound
Standard IV: Standard IV: PlanningPlanning
• A Plan of care is:• WRITTEN-but allows for changes/updates• Is individualized• Identifies priorities• Reflects client abilities and client involvement• Indicates responsibilities for actions
Standard V: ImplementationStandard V: Implementation
• Interventions:• Are directed by nurse’s level of training and
education• Are safe, timely, ethical• Are documented• Are accessible and Retrievable
Standard VI: EvaluationStandard VI: Evaluation
• Is systematic, ongoing and based on outcomes
• Involves client (student), teacher, parent• Includes ongoing revisions and updates
Psychiatric/Mental Health Needs and Psychiatric/Mental Health Needs and ConditionsConditions
• Eating disorders• Characterized by obsession/fear of weight gain• Anorexia nervosa• BulimiaInterventions:Initial/Annual weight measurementDirect observation at lunchInterviewRefer
Behavior disordersBehavior disorders• Attention deficit hyperactive disorder
(ADHD)• Most common neurobehavioral disorder
affecting school children (AAP. 2000)
• Thought to be a dysregulation of neurotransmitters in frontal cortex
• Can be genetically transmitted• Can lead to difficulties in school,
underachievement, poor interpersonal relationships, low self-esteem
Types of Attention Deficit Types of Attention Deficit DisorderDisorder
• Hyperactive variety• Makes careless mistakes, easily distracted• Difficulty in playing quietly, often interrupts • Has difficulty controlling physical and verbal actions
• Inattentive variety• Difficulty in sustaining tasks, organizing tasks, • Seems not to listen or follow through on tasks
• Mixed variety
Nursing assessmentNursing assessment
• Verify that student is aware of problem• Check hearing and vision• Verify behavior symptoms in a variety of
settings through direct observation or/and• Use of object rating scales by many teachers
and parents• Check with ESE coordinator for history of
perceptual/process problems
Treatment: ADHDTreatment: ADHD
• Pharmacological• Stimulants• Amphetamines• Non-stimulants• Second line medications (used if no success with first
line meds. and behavior is out of control)
• Effectiveness judged by changes in behavior
Treatment: ADHDTreatment: ADHD
• Non-pharmacological Interventions• Assistive devices• Placement to avoid distractions• Consistent routine• Additional supports
Behavior Disorders: Behavior Disorders: Oppositional Oppositional Defiant DisorderDefiant Disorder
• Student with ODD:• displays a pattern of developmentally
inappropriate, negativistic, defiant disobedient and hostile behavior toward authority figures.
• often looses temper or argues with adults, actively defying or refusing to comply with rules and requests. Blames others for own mistakes. Is annoying.
• are at GREAT risk for delinquent behavior and legal problems
Behavior disorders: Behavior disorders: Conduct DisorderConduct Disorder
• CD involves:• significant antisocial behavior, violation of the
rights of others and societal rules
• Identify CD by:• Aggression, stealing, lying, truancy, violence
against people and animals, destructiveness, cruelty and sexually coercive behavior
• Identify/Intervene/Refer early
Mood Disorders:Mood Disorders: DepressionDepression
• One of the most prevelant mental health conditions in children
• Has potential to have significant long term effects for teens and adults is not treated
• Clinical depression has considerable stigma vs joking or funny depression
Depression: Depression: Risk factorsRisk factors• Socio-economic status• Exposure to bullying, • Teasing, • Social isolation• Health problems• ADHD• Learning and
cognitive disabilities
• Parental mental illness• Parental physical
illness• Being a teen girl• Being a middle school
boy• Being American Indian,
Hispanic, Asian
• Experiencing racial discrimination
Depression: Depression: Diagnostic CriteriaDiagnostic Criteria• Must demonstrate 5 or more of the following in a
two-week period• Depressed/sad mood or Irritability/Anxiety• Sleep disturbance or hypersomnia• Fatigue or loss of energy• Inability to think or concentrate-indecisive • Alteration in eating pattern (increase or decrease)• Behavioral changes-more reckless, irritable • Crying, loss of interest in usual activities• Reduction in school performance• Thoughts of death without specific plan or suicide
attempt
Depression: Additional diagnostic criteriaDepression: Additional diagnostic criteria
• Positive family history of depression• Symptoms/feelings are not explained by
situational stressors, drug or medication use, medical/health problem
• Symptoms not part of a “mixed” or mania episode
Depression: Physiologic InformationDepression: Physiologic Information
• Depression has a neurobiological basis• Serotonin transport system dysregulation• Located on S allele• Brain volume is different/less in prefrontal
cortex and anterior cingulate cortex
Depression Assessment:Depression Assessment: School NurseSchool Nurse’’s Roles Role
• Complete initial (abbreviated) psycho-social intake
• Suicidal risk assessment/history• Verbalization of thought/plan-get details if student
can easily tell you. “ You seem really sad and down- have you ever thought of hurting yourself?”
• Past history of suicide thoughts/attempts
School NurseSchool Nurse’’s Role:s Role: Depression AssessmentDepression Assessment
• Maintain student safety• If not suicidal, schedule return visits to see you the next
day-notify in school support team• If has a plan, means and is despairing, do not leave
alone, follow school protocol• Intervene based on your knowledge, training and
willingness to be involved • Follow-up with parents at home re: access to treatment,
plan of intervention• Follow-up with student at school reentry• Advocate for student with mental health professional
Depression: Treatment options Depression: Treatment options
• Most antidepressants now “black boxed”, parents have inappropriate fear of “drugs”
• Most antidepressants are given once per day. Administration at school unlikely.
• Observation for side-effects critical. • Most side effects occur at beginning of treatment or
when dose is adjusted up or down. Monitor closely for sleepiness, headache, nausea/stomach pain/diarrhea,
nosebleeds with no past history of nosebleeds or coagulation problems, increased mania or grandiosity
Encourage involvement in Cognitive Behavioral Therapy (CBT)
Additional topics for review before Additional topics for review before certification testing certification testing
• Legal considerations of those with chronic physical or mental illness
• IDEiA • Emergency Action Plans• Physical Abuse and
Neglect and Sexual Abuse
• Special Procedures in Schools • Trach care and
catheterization
• Abuse Reporting• PTSD
• Family Violence• Illicit and performance
enhancing drugs• Trauma
• Hurricanes• Community Violence• Bullying and
harassment• Date related abuse and
violence
•Good Luck!!