Transporting Students with Disabilities

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Transporting Students with Disabilities

• Judith F. Harrigan, RN, MSN
• June 23, 2005

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Delegation

• First aide
• Know when to contact EMS
• Should not interfere with your ability to safely
  transport students
• Training should be provided
• Emergency intervention for common task that does
  not require nursing judgment
• Health care plan should be developed by school
  nurse
• Medication considerations
• School policy
• Permission to carry
• Level of responsibility of student
• Consideration for other students

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Health Care Plan for Transportation

• Used for students requiring special
  transportation
• Input from parents, school nurse, others
• Used as starting point to discuss medical
  concerns identify issues of concern
• Notify parent of responsibility to report changes
  that effect transportation
• Review annually

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When to Call EMS

• Unconscious or confused
• Difficult breathing or not breathing
• No pulse
• Uncontrollable bleeding
• Vomiting blood
• Poisoning
• 1st time seizure or lasts more than 5 minutes

• Injury to head, neck, or back
• Severe threat to limb
• Serious eye injury
• If moving could cause further injury
• Based on care plan
• According to district protocols

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Universal Precautions - Designed by CDC to
prevent spread of blood-borne diseases when
providing 1st aid

• Supplies hand cleaner, disposable towels,
  plastic bags, gloves, absorbent material
• Treat all human body fluids as though all were
  infected
• Clean up body spills promptly
• Inspect your skin. Cover open areas. Wear gloves
• Soak up spills with absorbent material. Cover
  with paper towel. Keep students away. Clean with
  bleach at bus garage
• Discard contaminated materials in sealable
  plastic bag
• Wash hands or use bactericidal cleaner after
  contact with body fluid
• Do not eat or touch mouth or eyes while giving
  1st aid

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Asthma - Airway are extra sensitive and become
inflamed when exposed to certain triggers, making
it hard to breathe

• Symptoms include
• Coughing
• Chest Tightness
• Shortness of Breath
• Turning Blue
• Wheezing
• Rapid, labored breathing
• Pulling in of skin around neck muscles, above
  collar bone, between ribs and under breast bone

• Difficulty carrying on a conversation due to
  difficulty breathing
• Difficulty walking due to breathing problems
• Shallow, rapid breathing
• Blueness (cyanosis) of fingernails and lips
• Decreasing or loss of consciousness

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Asthma - Triggers

• Exercise
• Colds (viral illness)
• Weather changes, esp. cold air weather changes
• Emotions (when upset or stressed)
• Irritants Chalk dust, dust, molds
• Animal dander
• Cigarette smoke, smog, strong odors (paint,
  markers, perfumes, sprays)
• Pollens (trees, grasses, and weeds)
• Dust and dust mites

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Asthma Management

• Avoid known triggers
• Take medication on a regular basis at home or in
  school
• Use an inhaler when symptoms occur
• Inhaler use should be allowed on the bus
• Health care plan should be developed by school
  nurse

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Asthma Inhalers
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Anaphylaxis Extreme life-threatening allergic
reaction to bee stings, certain foods, chemicals,
medications

• Symptoms include
• Itchy eyes or nose, flushed face
• Swelling of tongue lips, metallic taste
• Itchy red skin, hives
• Itchy throat, hoarseness, hacking cough,
  difficulty swallowing, choking

• Difficulty breathing, shortness of breathe,
  wheezing
• Vomiting, nausea, stomach pain, diarrhea
• Dizziness, drowsiness, sense of impending doom,
  loss of consciousness

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Anaphylaxis Management

• Administer epinephrine (injection) or benadryl
  (pill)
• Health care plan should be developed by school
  nurse
• Usually with Epi Pen - Dose is preset
• Student should be carrying appropriate medication
• Contact EMS
• Keep child calm quiet
• Provide fluids if able to swallow

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Epi Pen
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Diabetes Chronic disease in which body doesnt
make/use insulin is unable to digest sugar

• Can experience high blood sugar
• (not life threatening) will need insulin
  injection usually self-administered or can wait
  until student arrives at destination
• Give sugar free liquids. If breathing very fast,
  notify EMS or have parent meet the bus
• Can experience low blood sugar
• (life threatening) will need glucose
• Health care plan will be developed by school
  nurse
• Student may wear an insulin pump
• Student may test blood sugar level on the bus

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Insulin Pumps
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Blood Glucose Monitors
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Hypoglycemia (Low Blood Sugar)

• Mild low - hunger, irritability, shakiness,
  sleepiness, sweating, pallor, uncooperative,
  crying or other behavioral changes
• Treat with juice or snack that student will carry
• Moderate low - In addition to above, student may
  be combative, disoriented, or incoherent
• Treat with juice, snack, glucose gel, or frosting
  in a tube
• Severe low - Seizures or loss of consciousness,
  unable/unwilling to take gel or juice
• Medical emergency
• Treat with glucagon injection
• Call EMS

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Emergency Kit Contents

• 1 mg of freeze-dried glucagon (Vial)
• 1 ml of water for reconstitution (Syringe)

Combine immediately before use
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Administration of Glucagon
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Tracheostomy

• Surgical opening in the airway that allows air to
  go in out of lungs without passing through
  mouth or nose
• Tube is placed in the opening that allows for
  breathing clearing of secretions
• May be hooked to a ventilator, but then student
  will be accompanied by a nurse
• Will interfere with ability to talk clearly

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Tracheostomy Management

• Health care plan should be developed by school
  nurse
• Suctioning may be necessary. Student should have
  equipment training should be provided.
• If frequent suctioning is necessary, an aide
  should accompany student on bus
• Encouragement to cough may clear airway
  effectively
• Student should be kept away from open windows and
  places where dust/debris can get into airway

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Tracheostomy
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Seizures (Epilepsy)

• Seizures can be very frightening to the child
  those who witness them
• Generalized seizures originate in the entire
  brain affect the whole body
• Grand mal falls down has generalized jerking
• Petit mal (absence) brief loss of awareness,
  staring, do not fall
• Partial seizures originate in on part of the
  brain affect part of the body
• May or may not involve loss of consciousness
• Varied symptoms
• It is not necessary to know who has seizures as
  long as you know how to provide 1st aid

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First Aid for Seizures

• Stay calm
• Pull to a safe location
• Report to transportation office
• Note the time seizure starts ends
• Prevent others from crowding around. Reassure
  other students
• Put something soft under the head
• Turn student on his-her side
• Move things out of the way. Only move student if
  they are in danger
• Do not restrain. Allow seizure to take its course
• Do not put anything in the persons mouth. They
  cannot swallow their tongue.

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Loosen clothing
Turn on side
Cushion head
Time the seizure
Dont put anything in mouth
Dont hold down
First Aid for Seizures
As the seizure ends
Follow health care plan
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Status Epilepticus

• A medical emergency
• A seizure that lasts for more than 5 minutes (or
  longer than defined in health care plan) or
• One seizure occurs immediately after another
  without recovery between seizures or
• Student cannot be awakened 30 minutes after
  seizure has stopped
• Health care plan may or may not be available

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Kids with Motor Disorders
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Causes of Motor Disorders

• Cerebral palsy
• Brain injury
• Spina bifida
• Juvenile arthritis
• Amputations
• Muscular Dystrophy
• Osteogenesis Imperfecta

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Spinal Cord Injuries (trauma, spina bifida)

• Can involve legs only, arms legs, or shoulders,
  breathing, etc. depending on level of injury
• May not feel pain or heat in affected areas.
  Report bumps, bruises, cuts
• Balance may be a problem. Should always wear a
  seat belt
• Bowel bladder incontinence will probably be
  present. Care should be provided at home or in
  school
• May be in wheelchair /or use crutches
• Emotional, irritable, angry behavior is common
  during adjustment period
• May need help on off bus

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Spinal nerves
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3 types of Spina Bifida
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Brain Injury(Cerebral Palsy, TBI)

• Can involve legs, one side of body, or entire
  body
• May use variety of equipment
• May need assistance on off bus
• Poor balance, may fall to one side when sitting.
  Should always wear a seat belt
• Slow physical verbal responses
• Slurred, hard to understand speech
• Tremors or arms /or legs that cause jerking
  (i.e. foot will jerk off wheelchair foot pedal)
• Fear of movement, especially fast movement
• Startle reflexes that result from fast movement
  or loud noises may make them jump or become
  stiffer than usual

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Traumatic Brain Injury

• Can vary in severity
• Recovery can be uneven unpredictable can take
  months or years
• Programs must be flexible so that accommodations
  can be made
• Cognitive memory deficits, slowness of
  thinking responding, difficulty maintaining
  attention, impaired communication, reasoning,
  judgment problem solving
• Physical speech, vision, hearing, headaches,
  paralysis, seizures, spasticity, poor
  coordination
• Behavioral/emotional fatigue, mood swings,
  denial, anxiety, depression, anger, impulsivity,
  difficulty relating to others

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Brain function
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V-P Shunt

• Surgically implanted tube that creates a bypass
  to allow fluid to drain from ventricles in brain
  to abdominal cavity thus reducing pressure from
  abnormal fluid accumulation (hydrocephalus)
• .25-size shunt button on one side of head tube
  in neck is visible
• Seat student so seatbelt does not cross neck on
  side with tube head will not rest against hard
  surface at location of shunt button
• Notify parents or school staff of bumps to head
• Notify parents or school staff of unusual
  lethargy, seizures, vomiting

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Hydrocephalus V-P shunt
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Muscular Dystrophy

• Inherited, progressive incurable wasting of
  muscle tissue
• Usually able to walk until 8-9 years then will
  need wheel chair, braces, etc.
• Breathing will eventually be affected. Ventilator
  may be needed
• May not be able to prevent falls. Will need help
  getting up
• Climbing is difficult. Will need help getting on
  off bus.
• Weakness of arms makes is difficult for them to
  help someone lift them.
• Weakness in neck trunk interferes with ability
  to hold head or body erect
• Have difficulty coughing fighting off colds
  illness
• Bones are brittle. Be careful when moving them
• May have emotional problems coping with the
  progression of the disease

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Kids with Muscular Dystrophy
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Gastrostomy Tube

• Surgical opening through abdominal wall directly
  into stomach
• Tube is placed in the opening is capped except
  during feeding
• Way of giving food, medicines, fluids directly
  into stomach
• Used when student is unable to take food or
  cannot get enough nourishment by mouth
• Leakage should be reported to parent or school
  staff
• Probably will not be fed on bus unless they have
  a pump, then an aide should accompany the student
• Position seat belt so as not to interfere with
  ostomy or tube

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Gastrostomy Button (G-button or tube)
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Other Ostomies

• Surgical opening through the abdominal wall that
  provides an alternate way for elimination of
  stool or urine to occur
• Opening is called a stoma
• Depending on where in the intestine the ostomy
  is, the stool will be more or less formed and
  odor will vary
• Student wears a plastic bag to catch urine or
  feces
• Care will occur at home or in school
• If leakage is noted, let parent or school staff
  know

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Colostomy
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Oxygen

• Used to supplement when students have impairments
  of the heart or lungs that lead to problems with
  breathing or oxygenation
• Can be given through the nose (nasal prongs) or
  through a mask that covers the nose mouth
• Small tank will be provided for transport on the
  bus
• Many different delivery systems

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Kids on oxygen therapy (most of them are, anyway)
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Behavioral Issues

• Attention Deficit Disorder (ADHD)
• Tourette Syndrome
• Traumatic Brain Injury (TBI)
• Other mental health problems

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Behavior Management

• It is not unreasonable to expect good behavior
• Remember that students may not have control over
  their behaviors
• Students with severe behavior problems should
  have management plans
• All students have a right to be safe on the bus
• Additional adult assistance may be necessary
• Do not position in emergency exit rows

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Behavior Management

• Reasonable expectations
• Take your seat quietly and quickly, remain seated
  when the bus is moving and dont get out of your
  seat when the bus is moving.
• Keep your feet on the floor and never ever extend
  your hands, arms, head or any object out the
  window of a bus.
• Talk in a conversational tone, be courteous to
  the driver and schoolmates, and try not to
  distract the driver through misbehavior.

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Cancer

• Many different types out-of-control growth of
  abnormal cells
• Cause tumors, abnormalities of blood can be
  found in any part of the body

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Cancer- Things to Consider

• Frequent absences from school dont forget
  them!
• Fatigue, low tolerance for activity may need
  help on off bus with carrying books, etc.
• Fragile bones notify parents or school staff of
  falls, etc.
• Easy prolonged bleeding bruising, nosebleeds,
  bleeding gums universal precautions

• Nausea vomiting
• Susceptibility to infection notify parents of
  others with illnesses
• Pain, especially in joints
• Irritability, headache, lethargy
• Blurred vision
• Personality changes

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Kids with Cancer
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Central Venous Line

• Intravenous tube surgically implanted in a vein
  in the neck or chest
• Used to give IV feedings, fluids, /or
  medications or to take blood samples
• Insertion site must stay covered and clean
• Seat student so seatbelt does not interfere with
  line
• Care will be provided in school or at home
• Health care plan should address what to do if cap
  on end of tube comes off

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Central Venous Line (CVP or PICC Line)
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Points to Consider

• All children have a legal right to attend school
• Transportation is mandated service for students
  with disabilities
• Safe environment must be provided where potential
  problems are eliminated or minimized
  medications are allowed
• Each school district has a nurse you should know
  who that is
• Health care plans identify student needs plans
  for care
• Relevant medical information should be provided
  to bus drivers
• Insist on training information about
  health-related problems
• If you are designated to provide care, delegation
  from school nurse must occur
• If in doubt, report symptoms, ask questions

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Points to Consider

• Any medical situation creates a threat to the
  physical emotional safety of all students on
  the bus, including child who is having the
  medical problem.
• A medical emergency will compromise the
  commitment to order the driver will get behind
  schedule.
• The 1st priority is to the physical safety of all
  of the children, the driver, other motorists.
• Planning ahead can prevent more serious
  situations.
• The 2nd priority is to the child with the medical
  problem.
• The 3rd priority is the disorder created by
  children who are upset by the situation.
• Once the more critical aspects have been dealt
  with, the aftermath, including any potential
  emotional fallout for the children and the driver
  can be addressed.

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What You Should Know

• District policies
• Emergency information about specific students
• What to do in an individual emergency
• How to contact EMS
• Basic first aid
• Documentation requirements

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When You Should Ask for Help

• Training to administer emergency medications
• Epinephrine
• Asthma medications
• Glucagon
• Training to intervene in emergencies
• Asthma/allergies/anaphylaxis
• Seizures
• Injuries