Should a school nurse diagnose?

[kimmyann]

My son went to the school nurse last week because his throat hurt. I picked him up, took him home, checked his throat, gave him some meds & waited. By that evening he was fine, but about two days later came down with a cold.

Today he went to the nurse to see about getting some cough drops (he has a cold, one that all three kids have had this week) & the nurse proceeded to check his throat & declared he had strep. Even though his throat doesn't hurt. She called me & said I have to pick him up, take him to the Dr & he can't return to school without a note from the Dr. She said he had white spots in his throat. She would not even let him go get his things from class.

I had his sister (thank God she was home today) take him to the Dr & the strep test is negative, just as I knew. There was also no sign of white spots. Even the Dr thought this was very extreme for the nurse to do. Needless to say after the time, money & him missing class over this I am a bit ticked off. I could understand if he had a fever, or was even complaining about his throat, but neither was the case. So yes I called her & let her know that he does not have strep & until she obtains an MD after her name she should not diagnose people.

At the beginning of the year my DD went to the nurse because her ear hurt. The nurse said she had severe ear wax & I needed to flush her ears out. I knew something was wrong since she never complains of her ears. Went to the Dr & sure enough she had an ear infection. The Dr said it was good that I did not flush her ears, it would have been extremely painful.

 

[RitaE]

The strep thing I can see because it is a symptom of a highly contagious condition and effects the other people in the school which is her domain. But she shouldn't say "He has strep" it should be "I need a physician's clearance about this throat condition because it is possibly strep or something contagious."

The ear wax thing no. She should not be suggesting treatment.

 

[ols386]

My thought is that if she looked in his throat and thought she saw white spots, then she should let you know, and request that he be seen by a dr.

If there were indeed white spots, it could have been something other than strep throat, that could also be contagious, and might have required attention.

She's giving you her opinion as the school nurse. If she were actually doing any kind of procedure on him or giving him meds, other than OTC cough drops, then I'd have a problem with that, but it doesn't sound like she did.

 

[RitaE]

I will add that I've had more than my share of negative experiences over the years with school nurses and my children are not encouraged to go there with medical problems. They are told to just have to office call me if there is a problem.

 

[ols386]

I will add that I've had more than my share of negative experiences over the years with school nurses and my children are not encouraged to go there with medical problems. They are told to just have to office call me if there is a problem.

That's probably the best way to handle it.

 

[happygirl]

I don't have a problem with her doing that. My kids had strep but didn't have any spots in there throat, but the test came back postive.

 

[DopeyDame]

I think the lesson here is to not have your son go to the school nurse for something little like cough drops. If she thought he might have strep, I can understand her wanting it checked out by a doctor before infecting the rest of the school. She shouldn't have said "he has strep" but the function of the school nurse is to keep the kids all healthy, so if she had a reasonable thought that he might have something contagious, she certainly should ask that it gets checked out.

 

[npmommie]

No she should not diagnose, but she should be perfectly capable of giving her opinion of what might be happening. She should have said "this could be strep you should take him to the doctor to be sure"
White spots do not always mean strep.

 

[Pea-n-Me]

School nurses operate under the Nurse Practice Act and the School Nurse Association for their state (and possibly other associations). They are there because they're trained, experienced and expected to act under the obligations of their licenses.

And unless you were actually there during the conversation with your son about the "strep", you really don't know exactly how it was phrased.

There is likely a school policy concerning the findings of strep.

So yes I called her & let her know that he does not have strep & until she obtains an MD after her name she should not diagnose people.

Incredibly rude and ignorant thing to say.

 

[msheriffm]

As a teacher I recommend that you send an e-mail to the principal. My district in CA would go crazy if a nurse did that. They are so caught up on being sued that they would only recommend that a child go to the doctor. The only way children are sent home is with a fever and the secretaries check for that. Our district of about 5,000 students only has 2 nurses which spend almost all there time tracking diabetic children's blood sugar level. I think your nurse is really putting your school district in a situation of liability and you should inform somebody of her actions.

 

[scrapquitler]

My son went to the school nurse last week because his throat hurt. I picked him up, took him home, checked his throat, gave him some meds & waited. By that evening he was fine, but about two days later came down with a cold.

Today he went to the nurse to see about getting some cough drops (he has a cold, one that all three kids have had this week) & the nurse proceeded to check his throat & declared he had strep. Even though his throat doesn't hurt. She called me & said I have to pick him up, take him to the Dr & he can't return to school without a note from the Dr. She said he had white spots in his throat. She would not even let him go get his things from class.

I had his sister (thank God she was home today) take him to the Dr & the strep test is negative, just as I knew. There was also no sign of white spots. Even the Dr thought this was very extreme for the nurse to do. Needless to say after the time, money & him missing class over this I am a bit ticked off. I could understand if he had a fever, or was even complaining about his throat, but neither was the case. So yes I called her & let her know that he does not have strep & until she obtains an MD after her name she should not diagnose people.

At the beginning of the year my DD went to the nurse because her ear hurt. The nurse said she had severe ear wax & I needed to flush her ears out. I knew something was wrong since she never complains of her ears. Went to the Dr & sure enough she had an ear infection. The Dr said it was good that I did not flush her ears, it would have been extremely painful.

No, the nurse cannot diagnose. But she can evaluate (which she DID, but she should have said "I SUSPECT that he has strep), and suggest that you send him to the doctor.

That said, not every case of strep throat involves a sore throat. My DD gets strep all the time and very rarely has the sore throat that most people experience. It is also NOT unusual for the quick strep test to come back negative but to find out later that the problem is in fact strep throat (often diagnosed later with a blood test). This is what happened with my DD last time she had it.

I'm also curious about your son going to the nurse for cough drops. Here, the school nurse cannot give cough drops (or anything else that wasn't previously sent in by the parent, accompanied by a signed doctors order)

 

[kaleighmariesmom]

we had the complete OPPOSITE thing happen to us with DD a few months back. DD was fine when she went to school then she (6 years old) started to fell sick and her ear hurt. The nurse said there was nothing wrong with her and sent her back to class. DD came home crying her ear hurt so bad and I took her to the dr where they said she had a double ear infection.

DD is only in kindergarden but now we know if she doesn't feel good to just have her call us and not go to the nurse or just have the nurse call us. Instead the nurse sent home a note saying DD said her ear hurt (which I got AFTER we went to the dr office).

 

[Coconut36]

The strep thing I can see because it is a symptom of a highly contagious condition and effects the other people in the school which is her domain. But she shouldn't say "He has strep" it should be "I need a physician's clearance about this throat condition because it is possibly strep or something contagious."

The ear wax thing no. She should not be suggesting treatment.

I agree. I can see her saying "it looks like strep" and say you need a Dr to check him out before he can return. They take strep and some other illnesses like that seriously at the schools around here..they send notes home when a child has been diagnosed with it in your child's class..etc. When the nurse called did she say the exact words "he has strep" to you or did this come from your son? If when you spoke to her she said "I suspect/I am concerned it is" or anything else implying she saw potential symptoms without declaring it a fact then I think that is fine. If she said it as 100% fact I would say she was in the wrong however I would also cut her a bit of slack in that she might have meant to add "I think it looks like" or something like that and didn't by mistake. According to my Ped the "sick" season here has hit really late..so if your kid was one of many she had to call parents about she might have been a bit rushed in her speech and didn't mean to imply a diagnosis. To call her up and say things like "until you have an MD after your name" is rude and unnecessary. A simple phone call stating the Dr confirmed it was not strep and a note would be sent is enough.

The ear wax thing..no.

ETA-One thing to keep in mind is that the rapid strep test is not 100% accurate. Our Ped always does a culture in suspected strep cases. I never test positive on the rapid but do in the culture so it is something to remember.

 

[ccgirl]

In my DD's school the nurse can't even give out cough drops without a prescription. They do not diagnose. But, will call for fevers or if the child is complaining.

I think both sides made mistakes on this one.

 

[luvmy3]

My son went to the school nurse last week because his throat hurt. I picked him up, took him home, checked his throat, gave him some meds & waited. By that evening he was fine, but about two days later came down with a cold.

Today he went to the nurse to see about getting some cough drops (he has a cold, one that all three kids have had this week) & the nurse proceeded to check his throat & declared he had strep. Even though his throat doesn't hurt. She called me & said I have to pick him up, take him to the Dr & he can't return to school without a note from the Dr. She said he had white spots in his throat. She would not even let him go get his things from class.

I had his sister (thank God she was home today) take him to the Dr & the strep test is negative, just as I knew. There was also no sign of white spots. Even the Dr thought this was very extreme for the nurse to do. Needless to say after the time, money & him missing class over this I am a bit ticked off. I could understand if he had a fever, or was even complaining about his throat, but neither was the case. So yes I called her & let her know that he does not have strep & until she obtains an MD after her name she should not diagnose people.

(to the bolded) I can't believe you said that to her, I agree with the pp, it was incredibly rude.
Personally, I wouldn't have an issue with any of what happened. If she suspected your child of having strep, then it is her job to keep him out of the general school population. She was probably following district protocol for a highly contagious disease. Instead of focusing my anger at her, I'd just be relieved that my kid didn't have strep.
Also, from experience, a negative test at the doctor's office doesn't mean your child doesn't have strep. Two of my kids have had negative strep tests at the doc's, yet the test that was sent out came back positive for strep.

 

[Wishing on a star]

No, in general, a nurse should NOT actually diagnose.

However, there are rules and laws...
They probably ARE required to send all children with suspected cases of certain highly infectious diseases home.
There are usually specific protocols to be followed re: strep, fever, etc....

While she may not have handled this in the exact best way.
I think there is a fine line.

When DS was in school, they ignored the law, and allowed his classmate, who was often RIGHT next to him, to come to school and STAY in school, with a very obvious case of Strep. It was so bad, that after I saw her, I stopped and mentioned it to the Vice Principal who was in the hallway, as I exited the school.

A few days later.... Guess what.... At that point, I was the one who was upset when I was the one with a very, very sick child, time off, doctor's visit, bills, etc.....

 

[Pea-n-Me]

I think you are assuming that the white spots (exudate) were what caused the nurse to "exclude" him (school talk for having to leave school).

It was likely more, after an assessment was conducted.

You said she saw your son last week because his throat hurt. So this "upper respiratory illness" is something that's been going on for a week.

My son went to the school nurse last week because his throat hurt. I picked him up, took him home, checked his throat, gave him some meds & waited. By that evening he was fine, but about two days later came down with a cold.

Next, this is confusing. You say his throat didn't hurt yet he went there specifically to ask for cough drops. I associate cough drops with throat pain - cause God knows they don't do much to stop a cough. (I usually send some with my kids when they need them. I didn't know schools provided cough drops?)

Today he went to the nurse to see about getting some cough drops (he has a cold, one that all three kids have had this week) & the nurse proceeded to check his throat & declared he had strep. Even though his throat doesn't hurt. She called me & said I have to pick him up, take him to the Dr & he can't return to school without a note from the Dr. She said he had white spots in his throat. She would not even let him go get his things from class.

Here is a typical algorythm that a school nurse would follow. As you can see, there's a lot more that goes into it than what meets the eye:

Sore Throat (Pharyngitis)

Infections of the throat may be caused by either viruses or bacteria, but the vast majority of infections are viral. Because it is not possible to know whether the infection is viral or bacterial by inspection, a referral for a throat culture may be necessary in order to identify an infection caused by bacteria, such as Streptococcus. An untreated streptococcal sore throat can lead to serious complications, such as rheumatic fever or nephritis.

About 10 to 20 percent of children who present with sore throat have a
Streptococcus infection (strep throat) as the cause of their pharyngitis. The typical incubation period for strep throat is one to three days. Viral infections of the throat usually last three to four days as part of a cold or upper respiratory infection.

The following list of key questions and key physical examination components are commonly used to obtain subjective and objective information when assessing the student who complains of a sore throat.

Sore Throat: Questions (Subjective Data)
Question Action

1. Name and age of student? Obtain health record.

2. How long has the sore throat been
present? How severe is the discomfort?
Any sore throat that is characterized as very
painful or has been present beyond 24 hours
should be evaluated by a licensed health
professional that same day.

3. Are there any associated symptoms, such
as cold, cough? Sore throat associated with upper
respiratory symptoms is likely to be caused
by a virus.

4. Does the student have the following
symptoms: headache, rash, chills, or
abdominal pain? Sore throat associated with these symptoms
is more likely to be caused by bacteria.

5. Has the student had many sore throats or
strep infections in the past? If positive, the student should have a throat
culture in order to rule out strep throat, a potentially serious infection.

6. Does the student have any serious chronic
medical disorder, such as kidney disease, diabetes, or congenital heart disease? If positive, the student should be evaluated
by a licensed health professional that same day.

7. Has the student had recent contact with
anyone who has had strep throat or impetigo
(i.e., skin infection caused by Streptococcus)?
Sore throat following a recent contact with
someone who had strep throat or impetigo
warrants a throat culture in order to rule out
Streptococcus as a cause of the pharyngitis.

Sore Throat: Physical Examination Components (Objective Data)
Action Plan

1. Check the temperature.

2. Neck: Are the glands in the neck swollen
and/or tender?

3. Mouth: Does the throat appear red? Are
the tonsils enlarged? Is pus or exudate present on the throat or tonsils?
If positive for elevated temperature and
enlarged and tender glands with a red and
pus-like throat, the student needs to be
evaluated by a licensed health professional.

Sore Throat: Potential Causes
Assessment Plan

1. Viral infections.
If there is no rash, fever, difficulty swallowing, swollen or tender glands,
abdominal pain, or headache, the student most likely has a viral infection.
The symptoms may be alleviated by taking a non-aspirin pain reliever,
gargling with weak, warm salt water, and drinking some fluids.
Medication may require an authorized prescriber’s order and parental
consent depending on state law and school policy.

2. Bacterial infections.
Sore throat associated with such symptoms as fever, difficulty
swallowing, swollen and tender glands, abdominal pain, rash, or headache
is more likely to be caused by bacterial infections.
The student needs to have a throat culture performed. Usually the results
are available within 24 to 48 hours. If positive, the student should be
placed on antibiotics by the student’s primary care provider. Students are
considered not contagious after 24 hours of antibiotic therapy.

http://www.doe.virginia.gov/support..._guidelines/conducting_health_assessments.pdf

We do not know any of the answers to these questions but the school nurse did - as part of an assessment of the child.

the nurse proceeded to check his throat & declared he had strep

Interesting way you phrase it.

My guess would be that after her assesment, which would include evaluating all of the above, she said, "You have white spots on your throat that could be strep so you will need to see your doctor. I'm going to have to call your Mom to come get you. If it's strep, you can come back to school after you've been on antibiotics for 24 hours."

Of course, it's possible that it didn't come out this way at all and that she could have chosen her words better.

But it doesn't change the fact that if an assessment yielded findings warranting exclusion, that, unfortunately, it is what it is, even if the findings were ultimately negative. (Which a longer culture will yield.)

My kids' school nurse has been terrific and I work with her in a partnership when there are health issues going on. I think of her as my eyes and ears from a health perspective when I'm not there. I value her opinion and she values my input. I get her a nice gift twice a year. Have I been inconvenienced a few times to take my kids up to the doctors when things turned out "negative"? Sure I have. And that's ok, as we were referred for evaluation and I appreciated it. Has she made some good calls? Yes, she sure has, like when my son went to school last year just fine but by mid morning was wheezing and almost wound up in the hospital, she caught it and disaster was everted. I respect what she does. School nurses do NOT have an easy job.

 

[honeydiane1953]

No she should not diagnose, but she should be perfectly capable of giving her opinion of what might be happening. She should have said "this could be strep you should take him to the doctor to be sure"
White spots do not always mean strep.

This school nurse has probably just about seen it all. I would trust her. Sorry about the ear infection. I too am a nurse and we can JUST about tell you the same thing an M.D. can. Who do u think tells the doctor how you have done symtoms, etc. while u were there(hospital) and he wasn't?? GOD BLESS NURSES

 

[npmommie]

This school nurse has probably just about seen it all. I would trust her. Sorry about the ear infection. I too am a nurse and we can JUST about tell you the same thing an M.D. can. Who do u think tells the doctor how you have done symtoms, etc. while u were there(hospital) and he wasn't?? GOD BLESS NURSES

I agree. but technically she cannot diagnose. that is the practice of medicine not nursing. she can say what her assessment is and what she thinks, but to be technical she cannot diagnose.
nurse here too.

 

[Pea-n-Me]

Whether or not she can "diagnose" here is kind of a moot point.

Yes, it's the title of the thread and the OP's impression that she "diagnosed", but most of us here know what she really did was refer for diagnosis, or rule out strep.

(Of course, npmommie can diagnose because she's a licensed NP. )

To clarify the difference between what MD's do and what RNs do (although they often overlap), MDs diagnose illness and RNs diagnose response to illness. There is such a thing as nursing diagnosis which is used to plan the care of the patient. It is different from, but related, to a medical diagnosis.