Monday, March 25, 2002
Copyright © Las Vegas Review-Journal

SCHOOL NURSES: Prescription for Fulfillment

The expanding medical role now includes feeding tubes and insulin pumps


Stanford Elementary School nurse Jacqueline Arnold pours a liquid nutrition supplement into Billy Stoddard's gastrostomy tube as the fifth-grader watches TV.
Photo by Clint Karlsen.

It's just before noon at Stanford Elementary School, and Jacqueline Arnold is meeting Billy Stoddard for lunch.

Arnold makes her way through Stanford's hallways and finds Billy waiting for her in his fifth-grade classroom. Arnold greets Billy with an enthusiastic hello, and Billy responds with a happy smile.

Billy has a condition called Leigh's Disease. He's wheelchair-bound, he can't speak, he breathes with the help of a ventilator and tracheostomy, and he has only limited movement in his arms.

Billy also can't eat and must receive nutrition via a surgically implanted tube that leads into his stomach. And that's why Billy has two standing lunch meetings a day with either Arnold or Mary Laczniak, Stanford Elementary's school nurses.

Billy surely doesn't realize it, but he's a perfect, smiling example of how the school nurse has evolved during the past 10 or 20 years from simple purveyor of Band-Aids to multifaceted health care provider.

Sally Jost, assistant director for health services for the Clark County School District, said the district currently has about 150 school nurses, all of whom are registered nurses who hold at least baccalaureate degrees and substitute teaching licenses.

During a typical day, school nurses -- along with first aid safety assistants and specialized procedure nurses, the other two components of the scholastic health care triad -- will deal with cuts, bruises, stomachaches, earaches and other inevitabilities of kid life.

But they'll also deal with such more complicated medical conditions as asthma and diabetes, and perform such relatively intensive medical tasks as administering gastrostomy-tube feedings and helping kids with insulin injections.

Jacqueline Arnold, a school nurse at Stanford Elementary School, hurries back to her office after an appointment with a student.

A primary reason for the expansion of the school nurse's role is the continuing trend, begun in the 1970s, toward having kids with medical conditions attend regular classes whenever possible.

Gail Tomao, Snyder Elementary School's nurse, recalls that when she became a school nurse 24 years ago, "there weren't any children in the general school population who were considered medically fragile or who had any kinds of treatments or procedures.

"We didn't have to do catheterizations and trachs and ventilators and blood glucose and insulin (injections). That was very uncommon."

Such conditions as asthma, diabetes and attention deficit disorder now are fairly common among students. And, Jost said, "last year, who would have thought we'd be training our staff to be prepared for chemical warfare? But after the events of September, we had to go back and make sure people have at least some basis of understanding anthrax."

Social conditions also have helped to expand the scope of school nursing. For instance, Tomao said, "We didn't have homeless kids 24 years ago. There were people who lived on the streets, but certainly not like now."

"Another issue is the AIDS issue," Tomao continued. "We didn't have AIDS or HIV 24 years ago, and now we have children in regular schools who are living with HIV or AIDS and are part of the regular classroom."

School nurses also are charged with conducting health, vision and scoliosis screenings, screening follow-ups and referrals, health education and even caring for teachers and school staff when necessary.

"It's a really stimulating area of nursing," Jost said. "You use every skill you've ever had."

Arnold came to school nursing after working for more than six years at Sunrise Hospital and Medical Center, first on its adult oncology floor and then in its neonatal intensive care unit.

She first began hearing about school nursing from former colleagues who had entered the field. "When they came back to visit, they just did nothing but brag about how they loved to be a school nurse," Arnold said.

The relatively regular hours of a school nurse appealed to Arnold. But even more importantly, she said, "you take care of kids. You make a positive difference in their lives.

"That's one of the rewarding things. You can actually see a child grow over many years and help open the door to different resources that are out there."

Still, Arnold conceded that the transition from hospital nursing to school nursing wasn't easy at first.

"I must admit that first year as a school nurse is very stressful," she said. "You're learning a whole new area of nursing.

"A week before I was to start my job, they told me, 'You're going to be at a school where a child is going to be coming with a tracheostomy and a feeding tube.' That was a new thing, especially in a school setting. I had no idea."

Today, though, Arnold's twice-daily visits with Billy are just part of the daily routine. Arnold begins by listening to Billy's lungs to make sure they're clear then checks the ventilator to make sure it's working properly.

Billy's lunch takes the form of a liquid nutrition drink and a bit of bottled water, both of which are poured into his stomach tube. Under district regulations, only a nurse may perform this procedure.

Arnold notes that it's vital for a school nurse to have an easy rapport with kids and, toward that end, eschews scrubs for street clothes. But the rapport between Arnold and Billy is apparent.

Billy, she notes, "is a normal child. He loves snakes and lizards. He likes to watch WWF wrestling. He's a normal child who just has the inability to get up and walk around."

The feeding takes only about five minutes. Arnold then suctions Billy's breathing tube, a procedure that produces a few uncomfortable-sounding coughs from Billy during the minute or so he's off of the ventilator.

But, when it's all over, Billy again becomes the friendly kid with the disarming smile and the expressive eyes.

Sue Stoddard says it's comforting to know that her son will be well cared for while he's at school. And, she said, ensuring Billy would receive the medical care he needs "was really a nonissue here. There are a lot of other school districts where you've got to fight tooth and nail."

When Arnold returns to her office, she meets another cute example of how the school nurse's job has changed: First-grader Troy Wright has stopped by to have his insulin pump programmed.

Stanford Elementary School nurse Jacqueline Arnold programs Troy Wright's insulin pump in what has become a post-lunchtime ritual for the first-grader.

The process involves asking the boy what he's had for lunch and then calculating the carbohydrates he's consumed and the insulin the pump will have to deliver to him.

Troy's pump usually is programmed only once a day at school, Arnold said, but the boy does stop in two or three times a day to have his blood sugar checked.

For Troy, who was diagnosed with diabetes at age 3 1/2, it's all a matter of course. In fact, for the boy, the toughest part of the whole thing seems to be having to sit still while it's all being done.

Troy's mom, Kim Wright, said it's reassuring to know that Troy never is far from a registered nurse.

Before starting school, "he had just never been with anybody else other than myself or his father," she explained. "So even bringing him to school was kind of scary."

But, she says, "he's got a lot of people who care here."

For a school nurse, "there is no typical day," Tomao notes. "Every day is different. And you always start out with, 'Today I'm going to do this, and I'm going to get this done,' but there could be an emergency or a couple of sick kids."

And even if the job is more complicated than it was 10 or 20 years ago, "it's much more rewarding," Tomao said, "because the depth of involvement with the students is greater."

Arnold agrees. "Know what?" she asks. "School nursing is the best-kept secret. It's the best job."

She smiles. "It's the most rewarding job."