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!!