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dvanced practice nurses in child neurology recognize that school nurses have a key role in providing com-prehensive health services to children and adolescents and frequently inter-face to coordinate the care of students with chronic neurological conditions. Schools are bound by federal man-dates to provide a free and appropri-ate education for children with dis-abilities. The Rehabilitation Act Sec -tion 504 (U.S. Department of Education, 1973, 2008), the 1990 In -dividuals with Disabilities Educa tion Act, previously known as the Edu -cation for All Handicapped Children Act of 1975 (U.S. Department of Education, 1990, 1997, 2004), and the Americans with Disabilities Act Title II: State and Local Government Activities (U.S. Department of Justice, 1990, 2008) establish the mandates re -quiring schools to deliver health servic-es for children with chronic health conditions during the school day.

Continuing Nursing Education

Technologic and pharmacologic advances have improved school attendance for students with chronic neurological conditions. Supporting the special needs of these students presents challenges for parents, school nurses, school staff, and health care providers. Many school nurses have less confidence in managing some neurological conditions, thus identifying a need for continuing education. Education around a broad spectrum of common child neurology conditions can help school nurses blend educational, medical, and health services action plans. A curriculum was developed based upon the Child Neurology Telephone Encounter Guides (Sprague-McRae, Rosenblum, & Morrison, 2009). The curricu-lum uses the Child Neurology Process-Oriented Triage conceptual framework (Rosenblum & Sprague-McRae, 2009) and the Healthy Learner Model (Erickson, Splett, Mullett, & Heiman, 2006) to promote and maintain student health. This collection of child neurology educational and assessment content guides school nurses through in-person or telephone interactions with health care providers, students, and parents for selected child neurology issues.

Chronic Neurological Conditions

In the Classroom: A School Nurse Curriculum

For Sustaining a Healthy Learner

Julie M. Sprague-McRae and Ruth K. Rosenblum

Objectives and instructions for completing the evaluation and statements of disclosure can be found on page 281.

Julie M. Sprague-McRae, MS, RN, PPCNP-BC,is a Pediatric Nurse Practitioner, Depart -ment of Neurology, Kaiser Permanente, Fremont, CA; former Director of Clinical Prac -tice, Association of Child Neurology Nurses (ACNN); Lead Author for ACNN’s Child Neurology Telephone Encounter Guide, and winner of many community awards for her work in promoting child safety.

Ruth K. Rosenblum, DNP, MS, RN, PPCNP-BC, is a Pediatric Nurse Practitioner, Child Neurology, Santa Clara Valley Medical Center, San Jose, CA; Chair, Clinical Practice Committee, Association of Child Neurology Nurses; Assistant Professor, San Jose State University, San Jose, CA; and Coor dinator, NorCal DNP Program, a collaborative online program with San Jose State University and California State University – Fresno, Fresno, CA.

The cohort of children, teens, and young adults with chronic neurologic health conditions is at the health care and education system intersection (Thies, 1999). As their numbers grow, their special needs in the academic environment pose challenges for par-ents, school nurses, school administra-tors, and health care providers. For example, newer anticonvulsant med-ications have improved seizure con-trol, and children with epilepsy can attend school more regularly. In some school settings, seizure rescue medica-tions can be used for immediate treat-ment, often avoiding activating emer-gency medical services or a trip to the emergency department. Changing practice standards in the area of migraines and post-concussion man-agement have also enhanced assess-ment and symptomatic treatassess-ment, helping children attend school more regularly.

School nurses have varying levels of confidence in managing common chronic child neurological conditions (Olympia, Wan, & Avner, 2005), and there is an ongoing need for targeted continuing education and evidence-based practice. There is also a need for

a comprehensive and consolidated child neurology curriculum. Through the lens of two conceptual frame-works, the Child Neurology Process-Oriented Triage (Rosenblum & Sprague-McRae, 2009) and the Healthy Learner Model (Erickson, Splett, Mullett, & Heiman, 2006), this article approaches the development of a comprehensive, consolidated school nurse continuing education curricu-lum based upon The Child Neurology Telephone Encounter Guides (Sprague-McRae, Rosenblum, & Morrison, 2009).

Issues Related to the Care

Of Students with Chronic

Neurological Diseases

The special health needs of students with neurological conditions re -quire a chronic disease resource school nurse and other school nursing staff to develop and maintain a high level of clinical expertise. As a consequence, there is a need for ongoing, targeted continuing education. Based upon their experience as nurse practitioners in child neurology, the authors identi-fied four common neurological


condi-tions from school nurses: epilepsy/ seizures, headaches/migraines, tic dis-orders, and concussions. As clinical practices continually change, school nurses can benefit from updated edu-cational content.


Each year, approximately 200,000 people in the United States will be diagnosed with epilepsy, and 45,000 of these new cases will be among school-aged children (O’Dell & O’Hara, 2007). For many children and adults, their epilepsy is well controlled. School nurses, students, and families can ben-efit from ongoing know ledge and skills regarding epilepsy, seizures, safe-ty, medication management (daily antiepileptic drugs and rescue seizure medications), post-seizure evalua-tions, and emergency response.


Many children and adolescents experience headaches, and headaches are a common reason for school ab -sences. Bille’s (1962) classic study found that 40% of children have headaches by seven years of age, and 75% have them by 15 years of age. Mi graine prevalence is 5% to 10% in children younger than 15 years of age. Once a clinician has excluded an acute or chronic illness beyond headache (e.g., brain tumor), atten-tion turns to pain and symptom man-agement (Rosenblum & Fisher, 2001). In between episodes, the symptoms abate, and the child is able to attend school. The school nurse is in a unique position to assess the student, family, and academic needs. Oper -ating as a key player, the school nurse can develop care plans to support the child’s school attendance and/or cre-ate alterncre-ate methods for students to obtain necessary credits and classes.

Tic Disorders

Tics can be very distressing to stu-dents, families, teachers, and school nurses. Tics generally start between six and seven years of age and can be motor or vocal. Not all children with tics have Tourette syndrome, but Tourette syndrome is estimated to occur in 3 per 1,000 children (Centers for Disease Control and Prevention, 2009). Because tics are not harmful and rarely require medication, it is imperative that teachers, school nurs-es, and parents understand the etiolo-gy and course of tics, and strategies

lum was created based upon the Child Neurology Telephone Encounter Guides

(Sprague-McRae et al., 2009), part of a larger project with the Association of Child Neurology Nurses, the Child Neurology Society, and the Child Neurology Foundation.

The Child Neurology Telephone Encounter Guides were originally developed as a reference collection of specialized educational content for new or less-experienced registered nurses and advanced practice nurses in primary care and child neurology specialty settings. It quickly became apparent, however, that this resource could be adapted for a variety of set-tings, including school. The guides are a valuable resource for assisting school nurses with in-person or tele-phone child neurology encounters.

The guides were designed for sit-uations where the diagnosis may or may not have been established. They are presented as a toolkit with a three-part structure for each topic. The first part is a general narrative overview of pertinent areas for assessing a selected child neurology problem. The second part offers a more comprehensive operational approach, including a data collection tool that can be used for training or charting. The third part is the “pocket guide.” This condensed version is a quick reference tool that also guides areas of assessment but is more portable. Topics covered in the guides include epilepsy, alteration of consciousness, paroxysmal involun-tary movements, tic disorder, head -ache, post-concussion monitoring, and developmental delay.

This unique comprehensive col-lection of educational content is based upon the Child Neurology Process-Oriented Triage (ChiNePOT) conceptual framework, which was developed by Rosenblum and Sprague-McRae in 2009. This frame-work is built upon the synergistic benefit of blending knowledge, skill, and judgment to enhance patient care outcomes. Blending this frame-work with the educational content in the Child Neurology Telephone Encoun -ter Guidesprovides a solid foundation for developing a child neurology school nurse curriculum and aligns well with Healthy Learner Model (HLM) principles. The following sec-tions further explain ChiNePOT, the HLM, and the curriculum.

in a position to provide education (to school staff, students, and parents) and suggest appropriate academic accommodations as necessary.


Athletes are one group of school-aged students at risk for head injuries (Meehan & Bachur, 2009). Con -cussion and traumatic brain injury in children and adolescents are increas-ingly controversial topics in schools and sports programs. Fortunately, there is more attention around this issue; states are passing laws related to the management of concussed student athletes (e.g., California Assem -bly Bill 25 [2011]) and education of school athletic coaches (e.g., California Assembly Bill 1451 [2012]). School nurses, staff, and administra-tors need education on current return-to-play recommendations, and how to assess and triage students immediately after head injury. The return-to-play plan can generate controversy among parents, athletes, and coaches, but it is imperative that an athlete be free of post-traumatic symptoms and of all post-concussive symptoms at rest and with exertion (American Academy of Neurology, 2010, 2013; Cantu, 1998, 2001, 2009; Giza et al., 2013). Equally as important, but often poorly recog-nized, is a broader picture extending beyond athletics. Non-athletes must also be symptom-free during physical exertion to participate in physical edu-cation and other curricular activities. Other considerations should include the post-concussion impact on cogni-tive function, emotional stability, and psycho-social issues. School nurses play a vital collaborative role with health care providers as all students are transitioned, often with accommo-dations, back into the academic set-ting.

Child Neurology

Telephone Encounter


A comprehensive, coordinated effort is needed to integrate a broad spectrum of common child neurology conditions and to help school nurses blend educational, medical, and health services action plans. In response to the significance of these topics and the questions they gener-ate, the authors developed a child neurology school nurse continuing


Figure 1.

The Child Neurology Process-Oriented Triage Model


Knowledge Judgment









Note: The Child Neurology Process-Oriented Triage Model combines a thorough knowledge base, skill at data collection, and clinical judgment to appropriately interpret data and render safe and effective care.

Source: Copyright © 2008 R.K. Rosenblum & J.M. Sprague-McRae. Used with per-mission.

Child Neurology

Process-Oriented Triage


Process-oriented triage is a struc-tural format, thought process, or framework for the teaching and learn-ing of condition-specific information and development of action plans link-ing health care providers, families, students, and the school. Merging process and content in a global way allows for adaptability of a variety of patient care settings. ChiNePOT lends itself to chronic condition manage-ment in concert with the HLM.

The three elements of ChiNePOT are knowledge, skill, and judgment (see Figure 1). A thorough knowledge base is required to understand and synthesize pathophysiologic and pharmacologic elements of care, use evidence to base care on research as appropriate, and understand causes of error and allocation of responsibility and accountability. Skill in data col-lection from the student or parent and other health professionals is also central in employing the model in this context. Eliciting patient, family, and community values in the setting of a diverse student population is an ongoing challenge. Clinical judgment is the final overriding principle of this model. Knowledge and skill are cru-cial, but the practitioner must also appropriately interpret data to render safe, effective care. The school nurse’s combination of knowledge, skill, and judgment specifically related to child neurology conditions ultimately en -hances the child’s potential to be a healthy learner.

The Healthy Learner Model

(HLM) for Student Chronic

Condition Management

Erickson and colleagues (2006) developed the HLM. This model pro-poses a bridge between the medical model, focusing on the clinical set-ting, and school initiatives in the school environment. “The HLM is an integrated, coordinated effort to opti-mize the health status and support the academic success of children with chronic conditions” (Erickson et al., 2006, p. 312). The model is depend-ent upon two fundamdepend-ental prerequi-sites. The first is a professional school nurse with a baccalaureate degree who displays knowledge, skills, and expertise in all relevant areas. The

sec-Health Care Provider Family Professional School Nurse

Figure 2.

The Healthy Learner Model for Student Chronic Condition Management

Evidence-Based Practice Capacity Building Resource Nurse HealthyLearner Evaluation LEADERSHIP

Note: The aim of this model is to enable students with chronic conditions to be healthy, in school, and ready to learn.

Source: Copyright © 2006 Special School District #1, Minneapolis Public Schools Health Related Services. Used with permission.


vides ongoing data to assess process and outcomes and to guide program decisions. The HLM has several inter-facing features (see Figure 2) that together promote “high-quality care and positive outcomes” (Erickson et al., 2006, p. 313).

The center of the model is the healthy learner who is supported by an infrastructure and intricate pro cess. The leadership role is shared bet -ween school staff and members of the community. A key facilitator in this model is the school chronic disease resource nurse. This nurse has special-ized clinical expertise and operates as a champion, mentoring other school nurses. With an expertise in evidence-based chronic disease management and capacity building, the chronic disease resource nurse en courages partnerships between health care pro-fessionals, families, and schools. These partnerships are an integral part of optimizing student health, improving academic performance, and making students healthy learn-ers. With continual evaluation and leadership to enhance capacity build-ing, the model is dynamic. HLM is a much-needed framework for schools and the community to support stu-dents with chronic health conditions, helping them stay healthy in school so they can be present to learn (Erickson et al., 2006).

The Curriculum

HLM and ChiNePOT comple-ment each other. The HLM answers the question: Why is this curriculum necessary? The ChiNePOT answers the question: How is the curriculum best presented? Based on ChiNePOT principles (knowledge, skill, and judg-ment), the educational content in the

Child Neurology Telephone Encounter Guideswas adapted, and a child neu-rology curriculum was created for school nurses, focusing on their scope of practice.

In the curriculum, four child neu-rology school nurse curriculum topics – epilepsy, headaches, tic, and concus-sion – were developed, integrating several areas of assessment:

• Description of symptoms. • Medications and treatments. • Medical update: Childhood

ill-nesses and issues.

• General health and psychosocial issues.

Curriculum for Headaches – Summary

Pocket Guide: Headache Interval History Telephone Encounter Description of Symptoms

1. Identify headache classification and general status. 2. Identify longest headache-free period.

3. Identify date and description of last headache.

4. Describe typical headache frequency, type, location, pain quality, associated features, triggers, timing, aggravating factors, duration, patterns, changes in patterns, and level of disability.

5. Identify worrisome “red flags” (intractable vomiting, diplopia, occipital pain, weakness, or ataxia).

Medication and Treatments

1. List all current and past headache rescue and preventive medications and describe efficacy and frequency of use.

2. List other prescribed or over-the-counter (OTC) drugs, vitamins, nutritional, herbal, or homeopathic drugs, supplements, or substances.

3. Indicate strength, formulation, dosing schedule, compliance, recent dosing changes, duration of treatment, and frequency of use.

4. Indicate signs and symptoms of side effects, toxicity, or drug interactions. 5. Identify other non-medication therapies and efficacy.

Medical Update: Childhood Illnesses and Issues

1. Current age and weight.

2. Acute: Signs, and symptoms of recent illness.

3. Chronic: Status of other medical or physical co-morbid problems, disabilities, and environmental risks.

4. Laboratory or procedural testing: Imaging (CT or MRI) and other relevant labs or procedures (type, date, and results).


Headache Symptoms and Medical Update

Medication, Treatments, Childhood Illnesses, and Issues

• Access results of laboratory or procedural testing as appropriate.

• Consult with the child neurology provider as indicated, regarding drug side effects or interations (analgesic overuse), recent acute illness, pertinent lab results, indications for adjusting or adding medication (rescue or prophylac-tic), indications for further laboratory or procedural testing, status of medical co-morbidities and disabilities, acuity, need for acute intervention (urgent care or ED), and priority for follow up.

• Discuss with the family headache triggers, headache diary, supportive man-agement and as indicated, the use of rescue or prophylactic medication (dos-ing, side effects, drug interactions, and symptoms of analgesic overuse). • Review with the family guidelines for follow up: Headaches, worsening in

fre-quency, intensity, or duration; “red flags” (intractable vomiting, diplopia, occip-ital pain, weakness, or ataxia), drug side effects or worsening co-morbid medical problems or disabilities.

• Arrange interval follow up and insurance authorization as indicated (office or telephone appointment visit with child neurology provider or RN).

• Refer the patient to the primary care provider for symptoms of acute illness and update regarding headaches and management plan.

• Refer back to other specialists as indicated for worsening medical co-mor-bidities or disabilities.

General Health and Psycho-Social Issues

1. Sleep: Current patterns, changes in patterns, or problems with snoring. 2. Nutrition: Poor appetite, vomiting, loose stools, constipation, weight loss or

poor gain, inadequate access to food, excessive weight gain or pica. 3. Psychiatric co-morbidities (ADD/ADHD, anxiety, OCD, other): Status and

psychiatric care.

4. Behavior: Temperament; new, ongoing, or worsening behaviors; relationship to recent changes; provocative factors, and typical management.

5. Communication and social skills: Difficulties with peer or family relationships, communicating, teasing, or bullying.


• Family dynamics and coping. • Early intervention, school, and

therapy programs.

• Action plans blending topic-spe-cific educational, medical, social, and health service needs. Figure 3 provides an example of the quick view pocket summary for headaches drawn from The Child Neurology Telephone Encounter Guides. This guide facilitates eliciting an inter-val headache history and developing appropriate action plans. Initially, the focus is on a detailed description of headache symptoms and identifying “worrisome red flags.” Medications and treatments are reviewed, along with a medical update on co-morbid conditions, recent illness, and status of laboratory or procedural testing. An action plan is developed and may include further communication with primary and child neurology pro -viders around laboratory or procedur-al test results, as well as updates on headache history, medications, side effects, and the status of other co-morbidities. It also includes a discus-sion with the student and family related to headache triggers, headache diary, medications and side effects, and guidelines for follow up with health care providers.

The next area of assessment focuses on general health, psychoso-cial issues, family dynamics, and cop-ing. Details around sleep, nutrition, psychiatric co-morbidities, behavior, communication and social skills, fam-ily dynamics, financial or health insurance issues, parent and student understanding of headache, and level of concern and family support systems are elicited. The action plan ad -dresses any issues that arise. This may include a general discussion about headaches and a tailored approach to addressing headache issues. If indicat-ed, further discussion would include other health issues, nutrition, need for financial assistance, health insur-ance, social or mental health services, and community or educational re -sources. Further communication with primary care and child neurology providers may also be initiated as indicated.

The final area of focus is on school and therapy programs. This includes identifying intervention ser vices (early intervention, occupational therapy, physical therapy, speech therapy) and reviewing academic performance; social skills; educational testing; con-cerns about focusing attention,

learn-Figure 3. (continued)

Curriculum for Headaches – Summary

Family Dynamics and Coping

1. Status of psycho-social issues or changes in family dynamics or structure. 2. Financial or health insurance issues.

3. Parents’ and patient’s understanding of headache and level of concern. 4. Family support systems.


General Health, Psycho-Social Issues, Family Dynamics, and Coping

• Discuss with the family the nature of the headache and suggest strategies to address current issues and headache pattern changes.

• Provide information on nutritional, financial, and health insurance assistance programs if indicated.

• Offer referral or suggest return to social worker counseling or child psychia-try services if indicated.

• Encourage the use of community resources, supports, and specialty Web sites, and provide educational materials.

• Consult or update the child neurology provider as indicated regarding health, psycho-social family issues, and follow-up plan.

• Update the primary health care provider regarding health, psychosocial, or family issues.

School and Therapy Programs

1. Intervention services: Pre-school or therapies (PT, OT, speech, or adaptive PE).

2. School: Grade level, status academically and socially, classroom setting, educational or ADD/ADHD testing (dates and results), identified learning dis-abilities, attention and focusing issues, educational interventions (IEP, 504 Plan [last review date], resource, or tutoring), response to medication (pre/post-reports if medicated for ADD/ADHD or other issues), attendance, and school headache plan.


School and Therapy Programs If there are academic issues

• Verify if consent is on file authorizing the exchange of medical, educational, and therapy information; if not, obtain one.

• Encourage testing (educational or ADD/ADHD) and IEP or 504 Plan as appropriate.

• Request letters from therapists and teachers describing current progress. • Consider referral to school liaison and provide advocacy resources, patient

education materials, and specialty Web sites.

• Update or consult the child neurology provider regarding new or worsening academic, focusing, behavioral, or learning disability issues, efficacy of treat-ment if medicated for ADD/ADHD or other issues, need to adjust or add med-ication, attendance problems, and follow-up plan to address school issues. • Update or develop school headache management plan.

Note: A summary of the curriculum for headaches, addressing the description of symptoms; medication and treatments; medical update: childhood illnesses and issues; general health and psychosocial issues; family dynamics and coping; and school and therapy programs. Action plans are offered for relevant areas. Although originally developed for outpatient clinical practice, the pocket guide content is adapt-able and aligns well with the school nursing scope of practice. The child neurology workshops are presented with the modified school nurse curriculum.

Source:Copyright © 2009 Association of Child Neurology Nurses. Used with permission.


ing disability, or be havior; educational interventions (Individualized Educa -tional Plan [IEP] or 504 Plan); response to medications (if medicated); school attendance; and school headache plan. The action plan involves arranging consent for exchange of medical, edu-cational, and therapy information, encouraging further testing (educa-tional or at tention deficit/hyperactivi-ty disorder) as indicated, developing an IEP or 504 Plan for appropriate accommodations (secondary to med-ical condition), and providing parents with suitable community resources. It may also require further communica-tion with primary and child neurology care providers around academic focus-ing or behavioral issues, headache impact on school attendance, response to medication (if medicated), and input on developing a school headache management plan.

The child neurology school nurse continuing education curriculum has been successfully used for school nurse workshops through the Cali -fornia School Nurse Organization (CSNO). In 2011, the authors, on be -half of the Association of Child Neurology Nurses, presented a four-and-a-half hour child neurology workshop at the CSNO’s annual state conference in Fresno, California. Each participant received a copy of the

Child Neurology Telephone Encounter Pocket Guides, which served as the syl-labus. The re ception was so positive that in 2013, the workshop was repli-cated and expanded to a six-hour for-mat for their San Diego, California, conference. Based upon participant written evaluations and interactive workshop dialogue, school nurses rec-ognized they need up-to-date educa-tional content around chronic child neurology conditions. They wel-comed the content and realized its direct impact on student care. Just one example identified was the need to integrate new terminology around classifying headaches, seizures, con-cussions, and tic disorders.


The growing cohort of students with chronic neurological conditions presents an ongoing challenge for school nurses, teachers, and adminis-trators. As school nurses gain more knowledge and their skill levels increase, their judgment is enhanced, and they are better prepared to care for these students in the classroom.

There is a need to replicate this valuable curriculum for school nurses in every state. Advanced practice nurses in child neurology are in a unique position to provide this con-tinuing education on a wider scope, if the barriers of financial resources and infrastructure can be addressed. If interested, please contact the authors for further details through the Asso -ciation of Child Neurology Nurses (


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Continuing Nursing Education

Contact Hours

Chronic Neurological

Conditions in the Classroom:

A School Nurse Curriculum

For Sustaining a Healthy


Deadline for Submission:

December 31, 2015

PED 1311

To Obtain CNE Contact Hours

1. For those wishing to obtain CNE contact hours, you must read the article and com-plete the evaluation through Pediatric Nursing’s Web site.Com plete your eval-uation online and your CNE certificate will be mailed to you. Simply go to

2. Evaluations must be completed online

by December 31, 2015. Upon comple-tion of the evaluacomple-tion, a certificate for 1.3

contact hour(s) will be mailed.

Fees –Subscriber:Free Regular:$20


To provide an overview of a collection of child neurology educational and assessment curriculum for children with neurology conditions and their parents, health care providers, school nurses, and teachers.


1. Identify the four common neurological conditions that most frequently elicit questions from school nurses.

2. Describe the child neurology school nurse continuing education curriculum presented in this article.

Statements of Disclosure: The authors re ported no actual or potential conflict of interest in relation to this continuing nurs-ing education activity.

The Pediatric Nursing Editorial Board members reported no actual or potential conflict of interest in relation to this contin-uing nursing education activity.

This independent study activity is provided by Anthony J. Jannetti, Inc.(AJJ).

Anthony J. Jannetti, Inc. is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Com -mission on Accreditation.

Anthony J. Jannetti, Inc. is a provider approved by the California Board of Registered Nursing, Provider Number, CEP 5387.

Licenses in the state of California must retain this certificate for four years after the CNE activity is completed.

This article was reviewed and formatted for contact hour credit by Hazel Dennison, DNP, RN, APNc, CPHQ, CNE, Anthony J. Jannetti Education Director; and Judy A. Rollins, PhD, RN, Pediatric Nursing Editor.


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