It is the position of the National Association of School Nurses that the registered professional school nurse (hereinafter referred to as school nurse) is an essential member of the team addressing concussions. As the school-based clinical professional on the team, the school nurse has the knowledge and skills to provide concussion prevention education to parents, students and staff; identify suspected concussions; and help guide the student's post-concussion graduated academic and activity re-entry process. The school nurse collaborates with the team of stakeholders including health care providers, school staff, athletic trainers, and parents.
The number of school-age children who have sustained concussions increased over the past few years (Bakhos, Lockhart, Myers & Linakis, 2010). Each year, U.S. emergency departments treat an estimated 135,000 sports- and recreation-related traumatic brain injuries (TBIs), including concussions, among children ages 5 to 18 (Centers for Disease Control [CDC], 2007). While falls are the most common cause of these concussions in children, sports-related concussions in school-age children are rising at an increasing rate (Faul, Xu, Wald, & Coronado, 2010; Lincoln, et.al. 2011). Almost half a million emergency department visits for traumatic brain injuries (TBI) are made annually by children aged 0 to 14 years (Faul et al., 2010). This increase in concussions may be due in part to a greater awareness of the condition and its symptoms or increased rates (Lincoln et al., 2011). The actual incidence of concussions may be higher than is currently reported due to lack of standardization in reporting and underreporting (Guskiewicz, Weaver, Padua, & Garrett, 2010; Halstead, Walter & The Council on Sports Medicine and Fitness, 2010). A variety of concussion management guidelines are emerging. For example, the CDC (2009) has developed the Heads Up campaign for concussion prevention and management.
DESCRIPTION OF ISSUE
Concussions are considered to be a mild form of a traumatic brain injury and the potential for their occurrence in children is greatest during activities where collisions can occur, such as during physical education (PE) class, playground time, or school-based sports activities (CDC, 2009). Recognition of a concussion and immediate assessment is critical in preventing further injury and for post-concussion management. Any force or blow to the head and/or symptoms of a concussion in a student or athlete should be immediately evaluated by either the school nurse or designated, trained school personnel. A consensus statement approved by the 3rd International Conference on Concussion states that, although most people recover quickly and fully from a concussion, the time needed is often slower among young children and teens (McCrory et al., 2009). During this recovery phase, the student may have an array of physical, mental, and emotional symptoms, which can impact the student in the school setting. Children with diagnosed concussions require significant cognitive rest and a graduated re-entry plan to pre-concussion activities as determined by the licensed health care provider.
As the student returns to school after a concussion, the school nurse has a significant role in supporting the student. The school nurse collaborates with the parents, school staff, special service providers, the health care professionals, and the student in providing accommodations as the student transitions back to school. A collaborative team approach with all stakeholders involved provides for the best management of the student’s post-concussion (CDC, 2010c). The school nurse can initiate an accommodation plan/health care plan based on input from the health care professionals and school staff to provide the cognitive rest and support needed during recovery. Accommodations during the recovery process may include modifying or limiting school activities (Halstead et al., 2010; Majerske et al., 2008; CDC, 2010c). The accommodations may include allowing rest during the school day, postponing testing until symptom-free, pacing homework or assignments, limited physical exertion, and physical accommodations, as needed. The school nurse can provide on-going monitoring of post-concussion symptoms and act as a liaison with stakeholders. For students who have persistent symptoms, the school nurse can work with the provider and family to facilitate a Section 504 Plan and/or a referral for special education evaluation as needed.
Students are at a risk for increased emotional symptoms post-concussion during the healing process (Halstead, et al., 2010). Furthermore, when cognitive deficits persist, there is an increased risk of psychological symptoms including depression (Ruttan, Martin, Liu, Colella, & Green, 2008). Recognizing the potential for these emotional symptoms in recovering students, the school nurse can provide encouragement and information for the student and school staff that brain healing is a paced process and cannot be speeded as the brain needs time to rest and repair itself.
It is imperative that appropriate preventative guidelines and post-traumatic procedures are followed. Individualized, conservative management is recommended in treating children’s and teens’ post-concussion
(Halstead et al., 2010; Majerske et al., 2008; CDC, 2010c). Proper management with a suspected concussion includes observation for symptoms, assessment for symptoms, notification to parents/guardians, referral to a health care professional if symptoms are noted, and if no symptoms are present - instructions to parents or school staff for continued observation (CDC, 2010a). As the school health professional, the school nurse provides advocacy for the prevention of concussions by advocating for safe environments; education of students, parents and staff on concussions; and tracking students with concussions (CDC, 2010b).
Bakhos, L. L., Lockhart, G.R., Myers, R., & Linakis, J.G. (2010). Emergency department visits for concussion in young child athletes. Pediatrics, 126(3); e-550-556. doi: 10.1542/peds.2009-3101
Centers for Disease Control. (2010a). Heads up concussion in high school sports. Retrieved from http://www.cdc.gov/concussion/HeadsUp/high_school.html
Centers for Disease Control (2010b). Heads up concussion: Know your ABCs, a fact sheet for school nurses. Retrieved from http://www.cdc.gov/concussion/pdf/TBI_factsheet_NURSE-508-a.pdf
Centers for Disease Control (2010c). Heads up concussion: Know your ABCs, a fact sheet for teachers, counselors, and school professionals. Retrieved from http://www.cdc.gov
Centers for Disease Control. (2009). Heads up: Concussion in youth sports. Retrieved from http://www.cdc.gov/concussion/HeadsUp/youth.html
Centers for Disease Control and Prevention. (2007). Nonfatal traumatic brain injuries from sports and recreation activities --- United States, 2001—2005. Morbidity and Mortality Weekly Report 56(29);733-737. Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5629a2.htm
Faul, M., Xu, L., Wald, M.M., & Coronado, V.G. (2010,). Traumatic brain injury in the United States: Emergency department visits, hospitalizations and deaths 2002–2006. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Retrieved from http://www.cdc.gov/traumaticbraininjury/pdf/blue_book.pdf
Guskiewicz, K. Weaver, N., Padua, D., Garrett, W. (2000). Epidemiology of concussion in collegiate and high school football players. The American Journal of Sports Medicine, 28, 643-650.
Halstead, M. E., Walter, K. D. & The Council on Sports Medicine and Fitness. (2010, September). Clinical report--sport-related concussion in children and adolescents. Pediatrics 126 (3), 597-615. Retrieved from http://aappolicy.aappublications.org/cgi/reprint/pediatrics;126/3/597
Lincoln, A., Caswell, S., Almquist, J., Dunn, R., Norris, J., & Hinton, R. (2011). Trends in concussion incidence in high school sports: A prospective 11-year study. American Journal of Sports Medicine, 30 (10), 958-963. doi: 10.1177/0363546510392326 http://ajs.sagepub.com/content/early/2011/01/29/0363546510392326.full.pdf+html
Majerske, C.W., Mihalik, J. P., Ren, D., Collins, M. W., Reddy, C. C., Lovell, M. R., & Wagner, A. K. (2008). Concussion in sports: Post-concussive activity levels, symptoms, and neurocognitive performance. Journal of Athletic Training,43 (3), 265-274. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2386420/
McCrory, P., Meeuwisse, W., Johnston, K. Dvorak, J., Aubry, M., Molloy, M., & Cantu, R. (2009). Consensus statement on concussion in sport: The 3rd international conference on concussion in sport held in Zurich, November 2008. British Journal of Sports Medicine, 43 (Suppl I):i76–i84. doi:10.1136/bjsm.2009.058248 Retrieved from http://bjsm.bmj.com/content/43/Suppl_1/i76.full.pdf?sid=be1e932b-4778-4c8a-a629-f0f8dc3cd53a
Ruttan, L., Martin, K., Liu, A., Colella, B., Green, R. E. (2008, December). Long-term cognitive outcome in moderate to severe traumatic brain injury: A meta-analysis examining time and untimed tests at 1 and 4.5 or more years after injury. Archives of Physical and Medical Rehabilitation, 89 (Suppl 2): S69-S74.
Acknowledgement of Authors:
Anne L. Diaz, PhD, RN, NCSN
Leah J. Wyckoff, MS, BSN, RN
Adopted: January 2012