Screening Techniques for the School Nurse

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Screening Techniques for the School Nurse

• Introduction to School Nursing

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Screening Programs

• 704 KAR 4020(2)(11), The Board of Education
  shall adopt a program of continuous health
  supervision for all enrollees. Supervision shall
  include scheduled, appropriate screening tests
  for vision, hearing scoliosis.
• Only scoliosis is mandated in this regulation to
  be performed at grades six (6) eight (8). The
  specific scheduling (grades) for vision hearing
  is at the local districts discretion.

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August 2008

• In accordance with KRS 200.703, Early Childhood
  Development, all children enrolling in the KY
  School System must have a vision examination by
  an Optometrist or Ophthalmologist before entering
  school

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Visual Screening

• Screening for distance is the single most
  important test of visual ability
• Children are often unaware of their vision
  problem
• Detect prevent serious lifelong irreversible
  vision problems
• Has educational significance due to the
  relationship to learning
• 20/20 is considered normal vision

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Common Eye ProblemsMyopia (nearsightedness)

• Inability to see distant objects
• Thought to be hereditary
• The most common refractive error affecting 1 of
  6 year olds
• In infancy can be more severe than in school-age
  children
• Tends to worsen with age

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Strabismus

• Results from eye muscles not working together
• Difficult to detect-may be constant, come go,
  or alternate from one eye to the other
• One may remain straight then the other eye turn
  slightly inward, may score 20/20 on the eye chart
• Affects 3-5 of children
• If uncorrected, strabismus can result in
  amblyopia (loss of vision)

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Amblyopia (Lazy Eye)

• Reduced visual acuity in an eye (lazy eye), not
  adequately used during early childhood (often
  caused by strabismus)
• Is NOT OBSERVABLE must screen both eyes to find
  this condition
• Affects 2-5 of general population
• If untreated by age 6, permanent vision loss is
  likely
• Treatment involves patching the good yet to
  re-train the brain to accept images from the
  affected eye

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Other Vision Defects

• Astigmatism-light cannot focus clearly on the
  retina, often causing blurred vision
• Hyperopia- farsightedness inability to focus on
  nearby objects

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Appearance Signs

• eye redness or discharge
• swelling/crusting of the eyelids
• Haziness or clouding of the eye
• eye crossing or misalignment (strabismus)
• Eyes jiggle (nystagmus)
• Protruding eyes (proptosis)
• Drooping eyelids (ptosis)
• Alignment of the eyes
• Non-round pupils/pupil size

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Behavior Signs

• Constant heat tilt or face turn
• Squinting
• Rubbing eyes excessively
• Closing or covering one eye
• Holding objects close to the eyes
• Blinking excessively

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Compliant Signs

• Headaches
• Blurry vision
• Double vision
• Eyes itch, burn or feel scratchy
• Unusual sensitivity to light

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Vision Assessment/Acuity

• Vision acuity is assessed in the school age child
  by the chart or a vision instrument tester
• AAP recommends LEA Symbols or HOVT Letter charts
• Screen same procedure for both eyes
• Begin testing at the top of chart progress down
• If student wears glasses, test with glasses
• Recorded as last line on which 3 of 5 symbols
  identified correctly

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Supplies for the Chart Test

• Eye chart
• Tape measure
• INDIVIDUAL eye covers (may be made with
  construction paper with rounded corners or paper
  cups) to prevent the spread of infections
• Vision Screening logs

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Prepare the Screening Area

• Location that is quiet free from distractions
• Location with good lighting light colored walls
  no glare or shadows
• Attach the chart to wall, with the passing line
  at the students eye level
• Mark exactly 20 feet ( or 10, according to chart
  used) of distance from chart

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Prepare the Child

• Show the child the large letter symbols so he/she
  is familiar
• Place the child in a standing position at the
  20ft/10ft mark, facing the chart
• Teach the child to have both eyes open during the
  test (when covering either eye)

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Screening

• Test both eyes first, then the right left
• Test with glasses if applicable
• When testing one eye, occlude the other eye
• Begin at the top of the chart. If the line is
  read correctly, proceed to the next line
  down
• When one line is missed, move back up until the
  majority of letters/symbols are correctly
  identified

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• Move according to the speed of the student
• In linear testing, it may be necessary to use a
  pointer to indicate the letter
• To pass, more than half of the symbols/letters on
  that line (3 out of 5) must be identified
• Observe for eye problems (tilting of the head or
  peeking)
• Record visual acuity (the last successful line
  read, both eyes, right and left eye)

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Documentation

• Record the results as a fraction - i.e.,20/30,
  20/40
• The numerator (top) represents the distance from
  the chart to the childs eye
• The denominator (bottom) represents the
  last/smallest line read
• A reading of 20/50
• 20 testing distance from childs eyes to
  eye chart
• 50 smallest line student could clearly
  identify
• The larger the denominator/bottom number, worse
  the eyesight
• When using a vision instrument tester, follow
  manufactures direction
• Record screening results on flow sheets,
  cumulative/individual health record other
  appropriate records/documents

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Referral Criteria-Ages 3-5

• Refer if visual acuity is poorer than 20/40 in
  both or either eye
• Refer if there is a two line difference between
  the eyes even in passing range (i.e. 20/25,
  20/40)
• Refer if possible signs of visual disturbance are
  present

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Referral Criteria for Ages 6-Adult

• Refer if visual acuity is poorer than 20/30 in
  both or either eyes
• Refer if there is a two line difference between
  the eyes even in the passing range (i.e. 20/20,
  20/30)
• Refer if possible signs of visual disturbance are
  present
• Avoid using the word fail in front of the student
  or parent

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Hearing Screen

• Identifies children with hearing impairment
• Aids in planning for medical referral, treatment
  and educational programs
• Five to ten percent of school age children do not
  pass audiometric tests
• Approximately 2 of children will show permanent
  hearing impairment and require special
  educational services

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Effects of Hearing Loss

• Interference with normal speech language
  development
• Development of abnormal social growth behavior
• Interference with education human potential
• Isolation in a hearing world

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Hearing

• Measured in decibels (loudness)
• Normal speech is 50-70 decibels
• Sound also has pitch, high or low sounds, which
  is measured in Hertz
• Hertz- is the frequency/number of cycles per
  second of pure tone
• Low tone would be 250 Hertz
• Threshold- is the softest level at which one
  hears the frequencies

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Hearing Disorders

• 1. Sensorineural-permanent losses results from
  inner ear defect
• Causes- viral, bacterial infections, prolonged
  exposure to loud noises, congenital abnormality
  head trauma
• Treatment- hearing aids, speech therapy (lip
  reading)

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• 2. Conductive not permanent is the most
  common loss in children, interferes with sound
  transmission, may be mild or severe
• Causes- impacted earwax, foreign objects (beans,
  erasers, cotton), otitis media, congenital
  abnormalities and ruptured/scarred eardrums
• Treatment-Many cases respond to medical or
  surgical therapies, losses may fluctuate over time

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Effects of Hearing Loss

• Mild hearing loss (15-30db)-difficulty hearing
  faint or distant speech
• Moderate hearing loss (30-50db) difficulty
  hearing distant speech
• Moderate-Severe (50-70db)-difficulty with
  conversation unless loud
• Severe/deaf (70-90 db) may hear loud voice close
  to ear

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Testing

• Hearing is assessed in children 3 years and older
• The room should be as quiet as possible
• Tester may test him/herself to be sure the noise
  level in the room will not interfere with the
  testing
• The room should be large enough to accommodate a
  table, the audiometer and chairs for the tester
  and student
• Student chairs should be positioned so the
  student cannot see the operation of the
  audiometer.

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Pure Tone Screening Procedure

• Turn the audiometer on
• Check to make sure masking is turned off
• Output selector Red earphone on the right ear,
  blue earphone on the left ear
• The following test levels shall be followed for
  these frequencies

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• A. 1000 Hz 2000Hz 4000Hz
• B. 20 dB for sound proof room
• C. 25 dB for exam room
• Give verbal instructions for student to raise
  their hand when a tone is heard
• For children 6 and below more often may hand or
  drop a block when a tone is heard
• Without wearing the headset, demonstrate by
  turning the tone to 90dB and raise your hand when
  you hear the tone

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Screening

• Set frequency dial to 1000Hz
• Set hearing level at 20/25 dB (depending on room)
• Present the tone by pressing the tone level (to
  be assured the student is responding correctly,
  the tone may need to be presented several times)
• Once a desired response is received, continue the
  test as follows

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Exam Room Area

• Test right ear at 1000, 2000, 4000Hz at 25 dB
• Test Left ear at 1000, 2000, 4000 Hz at 25 dB
• If student does not respond to a tone, increase
  the hearing level to 30 dB. Beginning at 1000.

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• If no response increase to 40dB
• If no response increase to 50 dB
• If not response, switch the control to the left
  ear and follow the same procedure, increase by
  10db, decrease by 5dB
• NEVER GO ABOVE 50 dB

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Pass/Fail Criteria

• Screening test is failed is the student fail to
  hear any one tone, in either ear
• A re-screening should be administered in two
  weeks for the student, if the student fails a
  second screening, he/she should be referred for
  proper follow-up
• Document results on the appropriate forms

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Audiometer Screening Pointers

• If unable to obtain a rapid response, temporarily
  fail and retest later
• Present tones only at the screening levels
• Do not go higher than 50 dB with an unsuccessful
  student
• Do not let the student see the tester operate the
  tone level switch
• Do not look up each time a different tone is
  presented

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• As a general rule it is better not to indicate
  that a response is correct or incorrect to the
  student
• Do not require the student to raise the hand that
  corresponds to the ear that the tone is heard in
• The success of the screening depends on the
  skills of the tester, the testing area, and the
  function of the audiometric equipment

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Pupils difficult to test

• Teacher input regarding the students classroom
  performance is needed
• Gross testing procedures such as alerting (eye
  movement, head turn, facial expression), noise
  makers (finger snap, hand clap) when presented at
  varying loudness distance may be useful
• Parent input regarding past history, auditory
  awareness and responsiveness to sounds in the
  home environment
• Referral to outside agency (i.e. Commission for
  Children with Special Needs)

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Audiometer

• Check the audiometer headphones for proper
  functioning
• Calibration any needed repairs should be done
  annually. After each calibration the dealer/lab
  should provide a Certificate of Calibration
• If the unit uses batteries remove when unit is
  stored
• Turn off unit when not is use

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Body Mass Index-BMI

• CDC-Centers for Disease Control Prevention
  produced the Body Mass Index as a screening tool
  to determine obesity those at risk for
  weight-related health problems
• BMI- can be plotted for children after age 2
• BMI-the ratio of weight to height squared
• Height weight screening is used to identify
  children who may be at risk for abnormal growth
  patterns for their age, weight and/or heredity
• No mandated KY law for screening height weight
  (district may set policies requiring these
  screenings)
• KDE suggests these screening measured annually in
  preschool elementary one time during middle
  and high school

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• Approximately 17 (or 12.5 million) of children
  adolescents aged 2-19 years are obese.
• Since 1980, obesity prevalence among children
  adolescents has almost tripled
• Significant racial ethnic disparities in U.S.
  among children adolescents
• 1 of 7 low-income preschool-aged children is
  obese
• BMI in schools aids in surveillance screening
  purposes

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Obesity Impact

• Heart Disease, high cholesterol and/or high blood
  pressure
• Type 2 diabetes
• Asthma/breathing problems
• Social discrimination
• Sleep apnea
• Joint/musculoskeletal problems

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Measurement Procedures Height

• Essential that a quality meter is used, whether
  permanently fixed to the wall or portable
  (preferred installed with a level to the wall)
• Student should stand with head, shoulder blades,
  buttocks heels touching the wall, wearing only
  socks or bare foot
• Knees are straight and feet flat on the floor
  while student looks straight ahead
• The moveable headboard is lowered until it
  touches the crown of the head, compressing the
  hair
• Height is recorded to the nearest 1 cm or ¼ inch
• Read plot measurement on age gender specific
  growth chart and evaluate accordingly
• Height attachments on beam balance scales should
  never be used to measure height

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Measurement Procedure for Weight

• Balance beam or digital scales ( all scales
  should be zero balanced calibrated annually
  according to manufacturers instructions)
• Weigh student after removing outer clothing
  shoes (minimal clothing)
• Place student on the middle of the scale
• Weight is recorded to the nearest 0.1 kg or ¼
  pound
• Read plot measurements on age gender specific
  growth charts and evaluate accordingly
• Do not use bathroom or spring balance scales
• Always provide privacy

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• Once the BMI is determined, students age
  gender are used to select the appropriate growth
  charts (BMI for age)
• Find the students age on the horizontal axis
  the BMI value on the vertical axis to determine
  the BMI for age percentile

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BMI For Age Percentile Categories

• Obesity- BMI for age percentile gt 95th
• Overweight- BMI for age between 85th 94th
  percentile
• Normal range- BMI for age between 5th 84th
  percentile
• Underweight BMI for age lt 5th percentile

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Communication

• Handle results in a sensitive manner,
  non-judgmental use factual approach in providing
  education
• Give parents copies of information to take home
  and digest later in privacy
• If information is mailed home, follow-up with a
  personal contact
• Always check with local school/district policy
  before disseminating information

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BMI

• BMI age-for-growth charts can be used with
  children/adolescents ages 2-20 years
• Determine BMI value by plotting the height
  weight measures on CDC tables
• Download growth charts on the CDC web site
  http//www.cdc.gov/growthcharts
• CDC provides an online calculator to determine
  BMI at http//www.cdc.gov/nccdphp/dnpa/growthchart
  s/bmi_tools.htm by entering the height weight
  measurements

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Web Sites

• www.cdc.gov/Features/ChildBMI/
• www.cdc.gov/healthyyouth/obesity/bmi
• www.apps.nccd.cdc.gov/dnpabmi/
• www.cdc.gov/healthyweight/assessing/bmi/childrens_
  BMI/tool_for_schools.html
• www.shapeup.org/oap/entry.php