5.3 School Health, Occupational Health, and Disaster Nursing / Emergency Triage

School Health Nursing

School health nursing focuses on promoting the health, safety, and well-being of students and school personnel to optimize learning outcomes.

Core Programs and Nurse's Roles:

• Health Screenings: Regular screenings for visual acuity (Snellen chart), hearing impairment, dental health, scoliosis (Adams forward bend test), and nutritional status (BMI monitoring to address both wasting and pediatric obesity).
• National School Deworming Day (NSDD):
  • The Department of Health (DOH) and Department of Education (DepEd) mandate mass drug administration (MDA) for soil-transmitted helminth infections (ascariasis, trichuriasis, hookworm) twice a year for students aged 5 to 18 years.
  • Medications: Albendazole (400 mg single dose) or Mebendazole (500 mg single dose).
  • CRITICAL CLINICAL NURSING PRECAUTIONS:
    1. Parental Consent: Written parent/guardian consent is an absolute legal prerequisite before administering deworming drugs.
    2. Feeding Requirement: The nurse must ensure that the student has eaten a substantial meal before taking the deworming tablet. NEVER administer deworming medication on an empty stomach. Administering the drug to a hungry child increases systemic absorption, causing gastrointestinal distress, severe abdominal cramps, nausea, vomiting, and dizziness as the worms die and release toxins.
    3. Adverse Event Management: If a child experiences mild abdominal pain or nausea, reassure them and offer rest. If persistent vomiting or allergic reactions occur, refer to a physician immediately.
• WASH in Schools (WinS) Program: Promoting daily handwashing with soap, toothbrushing with fluoride toothpaste, and proper menstrual hygiene management in schools.

Occupational Health Nursing

Occupational health nursing applies nursing principles to protect and promote worker health and safety in various industries, guided by the Occupational Safety and Health Standards (OSHS) of the Philippines.

Workplace Hazard Classifications:

1. Physical Hazards: Noise (causing occupational hearing loss), ionizing/non-ionizing radiation, extreme temperatures (heat stroke or frostbite), inadequate illumination, and vibration.
2. Chemical Hazards: Exposure to toxic dusts, fumes, mists, gases, or solvents (e.g., lead poisoning in battery plants, silicosis in mining, solvent inhalation in manufacturing).
3. Biological Hazards: Infectious agents like bacteria, viruses, fungi, or parasites (e.g., hepatitis B, tuberculosis, or HIV exposure in healthcare workers).
4. Ergonomic Hazards: Poorly designed workstations, repetitive motions, heavy lifting, vibration, or static postures leading to Musculoskeletal Disorders (MSDs) such as carpal tunnel syndrome, tension neck syndrome, or low back pain.
5. Psychosocial Hazards: Workplace stress, high demands, shift work, bullying, harassment, and lack of support, contributing to burnout and mental health disorders.

Pre-Employment and Periodic Examinations:

• Pre-Employment Examinations: Performed to determine the physical and mental fitness of an applicant for a specific job description, establishing a baseline health status.
• Periodic (Annual) Examinations: Conducted to monitor worker health over time, detecting early signs of occupational diseases or work-related health deterioration (e.g., annual audiometry for workers exposed to noise >85 decibels).

Ergonomic Interventions:

Nurses educate workers on proper lifting techniques: bend at the knees, squat, keep the back straight, hold the load close to the body, and lift using the leg muscles, avoiding twisting the torso. Desk workers are taught to adjust chairs so feet are flat on the floor, thighs are parallel to the ground, and computer screens are at eye level.

Environmental Sanitation

Environmental sanitation concerns the control of environmental factors that influence disease transmission. The DOH monitors water safety and waste management.

Approved Water Supply Facilities:

• Level I (Point Source): A protected well or a developed spring with no piped distribution system. Users fetch water directly from the source. It is suitable for rural areas where houses are scattered. It typically serves 15 to 25 households, and the maximum walking distance to the source should not exceed 250 meters.
• Level II (Communal Faucet System / Standposts): Consists of a source, a reservoir, and a piped distribution network terminating in public faucets. It is appropriate for clustered rural communities. Each faucet serves 4 to 6 households, and the maximum walking distance should not exceed 25 meters.
• Level III (Waterworks System / Individual Connections): A system with a source, reservoir, treatment facilities, and a piped distribution network with individual household taps. It is typical in urban areas and requires metered billing.

Excreta Disposal and Toilet Types:

• Sanitary Toilets: Toilets that isolate feces from the environment. Examples include pour-flush toilets connected to a septic tank, flush toilets with water carriage, and Ventilated Improved Pit (VIP) latrines.
• Unsanitary Toilets: Open pit latrines, overhung toilets (perched over bodies of water), and pail systems, which facilitate transmission of fecal-oral pathogens (e.g., cholera, typhoid, amoebiasis).

Disaster Nursing and Emergency Triage

Disaster nursing focuses on mitigating the health impact of disasters. The disaster management cycle consists of four phases: Prevention/Mitigation (hazard mapping, zoning laws), Preparedness (drills, stocking supplies, planning), Response (active search, rescue, triage, immediate care), and Recovery (rebuilding, rehabilitation, mental health support/psychological first aid).

Mass Casualty Triage and the START Algorithm:

During a mass casualty incident (MCI), resources are overwhelmed. The goal of triage shifts from individual care to doing the greatest good for the greatest number. The START (Simple Triage and Rapid Treatment) algorithm is the standard tool used to evaluate victims in under 60 seconds based on RPM (Respiration, Perfusion, Mental Status).

START Triage Decision Rules:

1. Step 0: Can the patient walk?
   • If yes, direct them to a designated area. Tag them GREEN (Minor / Walking Wounded).
   • If no, proceed to Step 1.
2. Step 1: Assess Respirations (R):
   • Is the patient breathing?
     • If NO, open the airway manually (jaw-thrust or head-tilt-chin-lift).
       • If they start breathing, tag RED (Immediate).
       • If they still do not breathe, tag BLACK (Deceased / Expectant).
     • If YES, check the respiratory rate:
       • If respiratory rate is greater than 30 breaths per minute, tag RED (Immediate).
       • If respiratory rate is less than 30 breaths per minute, proceed to Step 2.
3. Step 2: Assess Perfusion (P):
   • Check the radial pulse or capillary refill time (CRT):
     • If the radial pulse is absent OR capillary refill is greater than 2 seconds, tag RED (Immediate). Control any severe bleeding immediately with a tourniquet or pressure dressing.
     • If the radial pulse is present OR capillary refill is less than 2 seconds, proceed to Step 3.
4. Step 3: Assess Mental Status (M):
   • Ask the patient a simple command (e.g., "Squeeze my hands" or "Close your eyes"):
     • If they cannot follow commands (altered mental status, unconscious, confused), tag RED (Immediate).
     • If they can follow simple commands, tag YELLOW (Delayed).

Summary of Color Tags:

• RED (Immediate): Critical, life-threatening injuries but salvageable with immediate, simple intervention (e.g., airway obstruction, tension pneumothorax, uncontrolled hemorrhage).
• YELLOW (Delayed): Serious injuries requiring medical care, but not immediately life-threatening. The patient is hemodynamically stable (e.g., closed fractures, stable burns).
• GREEN (Minor): "Walking wounded." Superficial injuries, abrasions, minor cuts. Can wait hours for treatment.
• BLACK (Deceased/Expectant): Dead or has injuries incompatible with life given current resource constraints (e.g., open brain matter, decapitation, cardiac arrest in MCI).

Clinical Actions During Triage:

Only two medical interventions are permitted during active START triage:

1. Opening the airway (repositioning).
2. Controlling life-threatening hemorrhage (applying pressure or tourniquet). No other treatments, such as CPR or medication administration, are performed during the triage sweep.