School nursing is a specialized practice of professional nursing that advances the health, safety, and readiness to learn of students, supporting their academic success. The school nurse is often the only health professional in the building and serves the whole school community: students (including those with chronic conditions and disabilities), staff, and families.
Why it matters. Health and learning are linked: uncontrolled asthma, diabetes, hunger, poor vision, chronic absence, and mental health problems lower achievement. Schools reach nearly all children, so they are a powerful public health setting.
National frameworks
- NASN School Nursing Practice Framework (2024) — the National Association of School Nurses' updated framework (replacing the 2016 Framework for 21st Century School Nursing Practice). The student is at the center. Its principles are Care Coordination, Quality Improvement, and Community/Public Health, resting on the foundational principle of Standards of Practice (described in School Nursing: Scope and Standards of Practice), with Leadership overlapping all of them.
- Whole School, Whole Community, Whole Child (WSCC) model — developed by ASCD and CDC (2014), with 10 components: health education; physical education and physical activity; nutrition environment and services; health services; counseling, psychological, and social services; social and emotional climate; physical environment; employee wellness; family engagement; and community involvement.
- Staffing: NASN's position is that every student should have access to a registered professional school nurse all day, every day. In reality, access varies widely by state and district.
Levels of prevention in schools
| Level | Examples |
|---|
| Primary | Health education, immunization compliance, safe environment, healthy meals, violence and bullying prevention |
| Secondary | Vision, hearing, and other state-mandated screenings; early identification of mental health concerns; communicable disease case-finding |
| Tertiary | Individualized plans for chronic conditions, medication and procedure management, return-to-learn after concussion or illness |
Care-planning documents
| Document | Purpose | Legal basis |
|---|
| Individualized Healthcare Plan (IHP) | Nursing care plan written by the school nurse for a student with health needs | Nursing standard of practice |
| Emergency Action/Care Plan (EAP/ECP) | Plain-language steps for staff in an emergency (anaphylaxis, seizure, hypoglycemia, asthma) | Derived from the IHP and provider orders |
| Section 504 plan | Accommodations so a student with a disability that substantially limits a major life activity has equal access (for example, blood glucose checks in class, snacks, extra water, rest breaks, elevator pass) | Section 504 of the Rehabilitation Act; ADA as amended in 2008 |
| Individualized Education Program (IEP) | Special education and related services for a student in one of IDEA's 13 disability categories (including "other health impairment") whose disability affects learning | Individuals with Disabilities Education Act (IDEA) |
A student with diabetes, asthma, epilepsy, or food allergy often qualifies for a 504 plan even with good grades. An IHP alone does not carry the legal protections of a 504 plan or IEP.
Delegation in schools. Medication administration and some procedures may be delegated by the RN to trained unlicensed assistive personnel (UAP) only as the state Nurse Practice Act and education laws allow. The RN keeps responsibility for assessment, planning, training, supervision, and evaluation, and delegates only stable, predictable tasks (the right task, circumstance, person, directions and communication, and supervision and evaluation).
Health services
- Screening: state laws set which screenings are required and at which grades (commonly vision and hearing; in some states scoliosis, BMI, dental, or tuberculosis risk). Screening is not diagnosis — refer positives and follow up until care is received
- Immunization compliance: school-entry requirements and allowable exemptions are set by each state; all states allow medical exemptions, and nonmedical exemptions vary. Clinically, the pre-2025 CDC/ACIP schedule is in effect after the March 16, 2026 court stay (under appeal); the AAP also publishes its own schedule, which many states follow
- Medication administration: requires a prescriber's order and parent or guardian permission; keep medications locked (except emergency medications that must be immediately accessible), count controlled substances, document every dose
- Emergency medications: all states allow (and some require) schools to stock epinephrine auto-injectors and many allow stock albuterol and naloxone; state laws generally allow students to self-carry asthma inhalers and epinephrine with authorization
- Chronic conditions: asthma action plans, diabetes medical management plans (glucose monitoring, insulin, glucagon), seizure action plans (rescue medication such as nasal or rectal benzodiazepines), anaphylaxis plans (epinephrine first, then call 911)
Communicable disease control
- Report notifiable diseases to the local health department and follow its exclusion guidance
- Varicella: exclude until all lesions have crusted; in vaccinated children with breakthrough disease that does not crust, until no new lesions have appeared for 24 hours
- Head lice: the AAP (2022) and NASN advise that students should not be excluded from school for head lice and do not endorse "no-nit" policies; notify the family discreetly and recommend treatment
- General illness: common policies keep children home with fever until fever-free for 24 hours without fever-reducing medicine
- Promote hand hygiene, respiratory etiquette, cleaning, and vaccination
Emergencies
- Unresponsive student: check responsiveness and breathing, call for help and 911, start CPR and get the AED if not breathing normally
- Emergency response plans, drills, staff CPR and first aid training, and stop-the-bleed readiness
- Concussion: state laws require removal from play when a concussion is suspected and written clearance by a licensed health care provider before returning; plan a gradual return to learn and return to play
Mental and behavioral health
- Screen and identify students at risk (depression, anxiety, substance use, self-harm); refer to school counselors, psychologists, social workers, and community providers
- Suicide risk: do not leave the student alone, notify parents and the crisis team per protocol, connect to 988 or emergency services
- Nurses do not diagnose psychiatric disorders or prescribe medication
Healthy environment and education
- Indoor air quality, asthma triggers, safe water and food (school food service follows food safety plans that control biological, chemical, and physical hazards), playground and lab safety
- Health education based on the National Health Education Standards; oral health, nutrition, physical activity, sexual health (per state and district policy), substance use prevention
- Provide direct care and triage; decide who returns to class, goes home, or needs emergency care
- Write IHPs and EAPs; participate in 504 and IEP teams as the health expert
- Train and supervise UAP; evaluate delegated care
- Coordinate care with families, health care providers, and community agencies
- Lead on health policy: medication, emergency, infection control, and wellness policies
- Collect and use school health data (absences, screenings, visits) for quality improvement
- Advocate for students' health equity and access
- FERPA vs. HIPAA: in most K–12 schools, health records kept by a school-employed nurse are education records under FERPA, not HIPAA protected health information. Parents (and students at 18) can inspect them; disclosure within the school is limited to officials with a legitimate educational interest; disclosure without consent is allowed in a health or safety emergency
- Confidentiality of minors: share information on a need-to-know basis; follow state minor-consent laws
- Mandated reporting of suspected child abuse or neglect
- Disability rights: schools must not exclude students because of health conditions and must provide reasonable accommodations (Section 504, ADA, IDEA)
- Scope of practice: nurses assess, screen, refer, and carry out prescribed treatment; diagnosis and treatment of conditions such as dental caries or psychiatric illness belong to licensed dentists, physicians, and other prescribers
- Documentation: objective, timely records of assessments, care, medication doses, notifications, and referrals
Case 1 — Anaphylaxis. A student with a known peanut allergy has hives, throat tightness, and wheezing after lunch.
Action: give epinephrine immediately per the emergency plan, call 911, position the student lying down (or sitting if short of breath), be ready to repeat epinephrine per protocol, notify parents, and document.
Why: epinephrine is first-line; delay increases the risk of death.
Case 2 — Head lice. A teacher sends a student to the nurse with live lice and asks that the child be sent home immediately.
Action: examine privately, keep the child in class until the end of the day, notify the parent confidentially, and give treatment information.
Why: the AAP and NASN do not support exclusion or no-nit policies; exclusion stigmatizes and causes lost learning.
Case 3 — Diabetes accommodations. A student with type 1 diabetes is doing well academically, but the parent requests glucose checks in class and snack access.
Action: develop an IHP and diabetes emergency plan and refer the family to the 504 team for formal accommodations.
Why: good grades do not rule out 504 eligibility; diabetes substantially limits a major life activity.
- Saying HIPAA governs most K–12 student health records — FERPA usually does
- Assuming an IHP gives the same legal protection as a 504 plan or IEP
- Excluding students with head lice or requiring no nits
- Returning an athlete to play the same day after a suspected concussion
- Delegating assessment or judgment tasks to UAP
- Diagnosing or treating (for example, deciding a student needs a psychiatric medication)
- Thinking school entry vaccine rules and screenings are identical in every state
- Giving antihistamine first in anaphylaxis instead of epinephrine
- School nursing supports health, safety, and readiness to learn
- NASN School Nursing Practice Framework (2024): Care Coordination, Quality Improvement, Community/Public Health on a foundation of Standards of Practice, with Leadership overlapping all
- WSCC model: 10 components with the student at the center
- IHP = nursing plan; EAP = emergency steps; 504 = accommodations for disability; IEP = special education under IDEA
- RN may delegate medication administration to trained UAP only as state law allows; assessment and evaluation stay with the RN
- K–12 health records are usually FERPA education records
- Varicella: exclude until lesions crust (or no new lesions for 24 hours in breakthrough cases); head lice: no exclusion
- Anaphylaxis: epinephrine first, then 911
- Concussion: remove from play; written clearance before return
- Screening must be followed by referral and follow-up