CHAPTER 30- SCHOOL HEALTH (PAGES 613-627)According to the Cent.docx

CHAPTER 30- SCHOOL HEALTH (PAGES 613-627)
According to the Centers for Disease Control and Prevention
(CDC) (2016), the healthy development of children and
adolescents is influenced by many societal institutions, and
after the family, the school is the primary institution
responsible for the development of young people in the United
States. The school environment is also a key setting in which
students’ behaviors and ideas are shaped. Just as schools are
critical to preparing students academically and socially, they are
also vital partners in helping young people take responsibility
for their health and adopting health-enhancing attitudes and
behaviors that can last a lifetime (CDC, 2017).
BOX 30.1 Youth at Risk
· • Every day nearly 3200 young people start smoking
(CDC, 2015).
· • Daily participation in high school physical
education classes dropped from 42% in 1991 to 27.1% in 2013
(CDC, 2017).
· • Seventy-five percent of young people do not eat the
recommended number of servings of fruits and vegetables.
· • Marijuana use among young people increased from
15% in 1991 to 46% in 2015.
From National Institute on Drug Abuse: National survey of drug
use and health, 2015. https://www.drugabuse.gov/national-
survey-drug-use-health
Academic success and healthy children and youth are closely
intertwined. It is impossible to achieve success in school
without maximizing the health of the students. School-age
children and adolescents face increasingly difficult challenges
related to health. Many of today’s health challenges are
different from those of the past and include behaviors and risks

linked to the leading causes of death such as heart disease,
injuries, and cancer. Examples of behaviors that often begin
during youth and increase the risk for serious health problems
are the use of tobacco, alcohol, and drugs; poor nutritional
habits; inadequate physical activity; irresponsible sexual
behavior; violence; suicide; and reckless driving (Box 30.1).
In the United States, approximately 55.6 million children attend
school every day (National Center for Educational Statistics,
2016). Their presence creates a unique opportunity for school
nurses to have a positive impact on the nation’s youth. The
primary providers of health services in schools are school
nurses, and there are approximately 73,000 registered nurses
working in schools in the United States (U.S. Department of
Health and Human Services [USDHHS], Health Services and
Resources Administration, 2010).
School nursing is a specialized practice of professional nursing
that advances the well-being, academic success, and lifelong
achievement and health of students. To that end, school nurses
facilitate positive student responses to normal development;
promote health and safety, including a healthy environment;
intervene with actual and potential health problems; provide
case management services; and actively collaborate with others
to build student and family capacity for adaptation, self-
management, self-advocacy, and learning (NASN, 2017). The
National Association of School Nurses (NASN) recommends
one school nurse for every 750 students in the general
population, one for every 225 students in mainstreamed special
education populations, and one for every 125 severely
chronically ill or developmentally disabled students; however,
caseloads vary widely, depending on mandated functions,
socioeconomic status of the community, and service delivery
model (NASN, 2015).
More than 21% of the nation’s children live in poverty
(National Center for Children in Poverty, 2017). Poverty is
defined as an annual income below $24,339 for a family of four
(U.S. Census Bureau, 2017). Decreased or inferior health care

has been linked to serious health problems, resulting in an
increase in absenteeism that may be correlated with failure in
school. The school nurse can effectively manage many
complaints and illnesses, allowing these children to return to or
remain in class.
TABLE 30.1
Racial and Ethnic Breakdown of Uninsured Children in the
United States in the Year 2012
Race
Number
Percentage
White
2.9 million
38.8
Hispanic
2.7million
38.1
Black
1.0 million
14.2
Asian and Pacific Islander
306,000
4.3
Data from Children’s Defense Fund: The state of America’s
children, 2014. http://www.childrensdefense.org/library/state-
of-americas-children/2014-soac.pdf.
Indeed, on a daily basis, school nurses see students with a
variety of complaints. Increasing numbers of children are being
seen in the school setting because they lack a source of regular
medical care. According to the Children’s Defense Fund (2014),
nearly 9.2 million U.S. children, or 1 in 11, do not have health
insurance. This is a decrease from the nearly 12 million in
previous years. Table 30.1 illustrates the racial and ethnic
breakdown of uninsured children in the United States in the
year 2012. Poor academic performance is strongly correlated
with the uninsured status of youth, and conversely, acquisition

of health insurance leads to an improvement in school
performance. Through education, counseling, advocacy, and
direct care across all levels of prevention, the nurse can
improve the immediate and long-term health of this population.
There is a need for mental and physical health services for
students of all ages to improve both their academic performance
and their sense of well-being. This chapter provides an
overview of school health and the role of the nurse in the
provision of health services and health education. It also offers
an in-depth look at the components of a successful school health
program and the major health problems of today’s youth.
History of School Health
Before 1840, education of children in the United States was
uncoordinated and sparse. In 1840, Rhode Island passed
legislation that made education mandatory, and other states
soon followed. In 1850, a teacher and school committee
member, Lemuel Shattuck, spearheaded the legendary report
that has become a public health classic. This report, known as
the Shattuck Report, has had a profound impact on school health
because it proposed that health education was a vital component
in the prevention of disease.
Public health officials and others soon realized that schools
played an important part in the prevention of communicable
disease. When smallpox broke out in New York City in the
1860s, health officials were faced with trying to implement a
widespread prevention program. They chose to target the
schools and began vaccinating children. This experience led to
the 1870 requirement that all children be vaccinated against
smallpox before entering school (Allensworth et al., 1997).
At that time, schools were frequently poorly ventilated and
lacked fresh air, effectively spreading diseases among the
children. Late in the nineteenth century, a practice of inspecting
schools began to identify children who were ill and exclude
them until it was deemed they were no longer infectious. Soon
thereafter, compulsory vision examinations became a

requirement to identify children who might have difficulty in
school. In 1902, New York City hired the first nurses to help
inspect children, educate families, and ensure follow-up
treatment. Within a few years the renowned nurse Lillian Wald
was able to show that the presence of school nurses could
reduce absenteeism by 50%. By 1911, more than 100 cities were
using school nurses, and by 1913, New York City employed 176
school nurses (Allensworth et al., 1997).
As they became more comfortable in their positions, early
school nurses began to take on more active roles in the
assessment of children, treatment of minor conditions, and
referral for more serious problems. In addition to identification,
treatment, and exclusion for communicable diseases and
screening for problems that might affect learning, other issues
quickly became part of school nurses’ practice. In the early part
of the twentieth century the temperance movement led schools
to teach children about the effects of alcohol and tobacco. Also
early in the twentieth century, “gymnastics” was introduced in
schools in an effort to promote physical activity. World War I
was a pivotal point for school health services, and the call for a
national effort to improve the health of schoolchildren emerged.
In 1918 the National Education Association joined forces with
the American Medical Association (AMA) to form the Joint
Committee on Health Problems and publish the report Minimum
Health Requirements for Rural Schools. This group also called
for the coordination of health education programs, medical
supervision, and physical education. By 1921 nearly every state
had laws that required physical and health education in schools.
Additionally, fire drills became part of safety education
programs introduced during and after World War I (Allensworth
et al., 1997).
Even though emphasis was placed on health services in schools,
barriers still existed. Many schools and cities were unwilling to
take on the task of providing primary health care for all
children. The idea that schools should simply identify and refer
problems to physicians was a common practice backed by the

AMA. By the 1920s, medical services and preventive health
services were clearly separated in the public health arena and in
the schools, thereby largely supported by each state, which
focused more attention on “health education.” The federal
government did not get involved with school health until the
passage of the National School Lunch Program in 1946. The
School Breakfast Program was implemented 30 years later
(Allensworth et al., 1997).
There was no impetus to change the direction of school health
programs until the 1960s and 1970s. During these decades there
was increasing publicity about children living in poverty and
the move to mainstream children with disabilities. These two
issues, along with an increase in the number of children of
immigrants, contributed to changes in school health programs.
During the 1960s the first nurse practitioner training programs
opened and made the inclusion of primary care services in
schools possible. In 1976 the first National School Conference,
supported by the Robert Wood Johnson Foundation, was held in
Galveston, Texas. After this conference a variety of school
health service models began to emerge with new partnerships
and ideas created to provide the most comprehensive health care
services for school-age children. In addition, the Education for
the Handicapped Act in 1975 mandated that all children,
regardless of disabilities, have access to educational services.
The 1980s and 1990s saw several measures aimed at improving
the health of schoolchildren. The Drug-Free Schools and
Community Act was implemented in 1986 to fight substance
abuse through education and was expanded in 1994 to include
violence prevention measures. During this period, the Centers
for Disease Control and Prevention (CDC), Division of
Adolescent and School Health, began funding state education
agencies to develop and implement programs aimed at alcohol
and tobacco use, physical education, and the reduction of
sexually transmitted diseases (STDs) and HIV infection among
the nation’s youth. Also, the federal government encouraged
states to use part of their maternal and child block grant monies

to fund school-based health centers.
The No Child Left Behind Act (NCLB) was signed into law by
President Bush in 2002. As part of the NCLB, the Safe and Drug
Free Schools and Communities Act (SDFSC) became effective
that same year. SDFSC supports programs that focus on
prevention of school violence and illegal use of alcohol,
tobacco, and drugs. This legislation promotes the involvement
of parents and communities in efforts and resources to create a
safe and drug-free environment in order to enhance student
academic achievement.
The Patient Protection and Affordable Care Act was signed into
law March 23, 2010, by President Obama. Under this act, an
initial 95 million dollars was awarded to 278 school-based
health centers (SBHCs) as part of a capital program to create
new sites and expand existing services in 2011. In 2012, an
additional 14.5 million dollars was awarded to 45 SBHCs for
expansion of services in medically underserved areas
(USDHHS, 2013). See the later discussion of SBHCs.
School health services vary widely among states and school
districts. There continues to be a lack of coordination among
providers, with no single agency responsible for tracking
services. Recognizing that there are differences among schools
in the United States and that important health information must
be delivered to children and adolescents, the USDHHS
addressed many related issues in the Healthy People 2020
program. Objectives targeting children and adolescents are
written for diverse areas, including physical activity, sex
education and HIV prevention, nutrition, smoking prevention,
injury prevention, and school absences related to asthma. The
Healthy People 2020 box lists a few of these objectives related
to school health.
School Health Services
The School Health Policies and Programs Study describes
school health services as a “coordinated system that ensures a
continuum of care from school to home to community health
care provider and back” (Allensworth et al., 1997, p. 153).

School health services goals and objectives vary from state to
state, community to community, and school to school. These
differences reflect wide variations in student needs, community
resources, funding sources, and school leadership preferences.
Many organizations, such as the American School Health
Association and NASN, are involved in the care and welfare of
school-age children and have compiled and adopted definitions,
standards, and statistics related to school health.
FIG. 30.1 The eight components of school health programs.
According to the School-Based Health Alliance (2014), there
are 2315 SBHCs located in 49 out of 50 states, including the
District of Columbia. Most SBHCs are staffed with a nurse, a
nurse practitioner, or physician assistant. The following
services provided in these centers typically include first aid,
medication administration, and preventive screenings (vision,
hearing, scoliosis, and acanthosis nigricans). Nearly all schools
maintain health records on students and, at a minimum, monitor
immunization status per federal and state laws. Most authorities
agree that comprehensive school health programs should have
the following eight components (Fig. 30.1): health education;
physical education; health services; nutrition services;
counseling, psychological, and social services; healthy school
environment; health promotion for staff; and family and
community involvement.
Healthy People 2020
Selected Objectives for School Health
· AH-5.6: Decrease school absenteeism among
adolescents due to illness or injury.
· AH-8: Increase the proportion of adolescents whose
parents consider them to be safe at school.
· DH-14: Increase the proportion of children and youth
with disabilities who spend at least 80% of their time in regular

education programs.
· EMC-1: (Developmental) Increase the proportion of
children who are ready for school in all five domains of healthy
development: physical development, social and emotional
development, and approaches to learning, language, and
cognitive development.
· EMC-4: Increase the proportion of elementary,
middle, and senior high schools that require school health
education.
· ECBP-5: Increase the proportion of the nation’s
elementary, middle, and senior high schools that have a full-
time registered school nurse–to-student ratio of at least 1:750.
· EH-16: Increase the proportion of the nation’s
elementary, middle, and high schools that have official school
policies and engage in practices that promote a healthy and safe
physical school environment.
· FP-12: Increase the proportion of adolescents who
received formal instruction on reproductive health topics before
they were 18 years old.
· IID-10: Maintain vaccination coverage levels for
children in kindergarten.
· IVP-27: Increase the proportion of public and private
schools that require students to wear appropriate protective gear
when engaged in school-sponsored physical activities.
· MHMD-6: Increase the proportion of children with
mental health problems who receive treatment.
· NWS-10: Reduce the proportion of children and
adolescents who are considered obese.
· NWS-2: Increase the proportion of schools that offer
nutritious foods and beverages outside of school meals.
· OH-1: Reduce the proportion of children and
adolescents who have dental caries in their primary or
permanent teeth.
· PA-4: Increase the proportion of the nation’s public
and private schools that require daily physical education for all
students.

· RD-5.1: Reduce the proportion of children aged 5 to
17 years with asthma who miss school days.
· SA-18: Reduce steroid use among adolescents.
· TU-3: Reduce the initiation of tobacco use among
children, adolescents, and young adults.
· V-2: Reduce blindness and visual impairment in
children and adolescents age 17 and under.
From HealthyPeople.gov: Healthy People 2020: Topics &
objectives.
www.healthypeople.gov/2020/TopicsObjectives2020/default.asp
x Accessed: February 21, 2018.
Health Education
An objective of Healthy People 2020 sets a goal that middle,
junior, and senior high schools provide health education courses
in priority areas. The CDC (2016) identified the following six
high-risk behaviors, utilizing the Youth Risk Behavior
Surveillance System (YRBSS), as needing to be targeted in
health education courses:
· 1. Alcohol and drug use
· 2. Injury and violence (including suicide)
· 3. Tobacco use
· 4. Poor nutrition
· 5. Lack of physical activity
· 6. Sexual behavior that results in STDs or unwanted
pregnancies
These problems and behaviors are preventable and often
coexist. They also lead to both social and educational problems
that contribute to our nation’s high dropout and unemployment
rates and crime statistics.
The National Health Education Standards were established to
promote positive health behaviors for students in all grades
(CDC, 2016). These standards give educators, administrators,
and policy makers a framework for developing and designing
health education programs in schools. The standards are written
to promote personal, family, and community health in students,

targeting grades 2, 5, 8, and 12. The standards provide a guide
for curricula development in health education and specify that
the students will (1) comprehend concepts related to health
promotion and disease prevention to enhance health; (2) analyze
the influence of family, peers, culture, media, technology, and
other factors on health behaviors; (3) demonstrate the ability to
access valid information, products, and services to enhance
health; (4) demonstrate the ability to use interpersonal
communication skills to enhance health and avoid or reduce
health risks; (5) demonstrate the ability to use decision-making
skills to enhance health; (6) demonstrate the ability to use goal-
setting skills to enhance health; (7) demonstrate the ability to
practice health-enhancing behaviors and avoid or reduce health
risks; and (8) demonstrate the ability to advocate for personal,
family, and community health.
BOX 30.2 Purposes of the Youth Risk Behavior Survey
System
· • Determine the prevalence of health risk behaviors.
· • Assess whether health risk behaviors increase,
decrease, or remain the same over time.
· • Examine the co-occurrence of health risk behaviors.
· • Provide comparable data among subpopulations of
youth.
· • Provide comparable national, state, territorial,
tribal, and local data.
· • Monitor progress toward achieving the Healthy
People 2020 objectives and other program indicators.
From Kann L, McManus T, Harris WA, et al.: Youth risk
behavior surveillance—United States, 2015, MMWR Surveill
Summ 65(No. SS-6):1–174, 2016.
In 1990, to learn more about high-risk behaviors among youth,
the CDC (2016) instituted the Youth Risk Behavior Surveillance
System. The YRBSS survey is conducted every 2 years among
selected high school students throughout the United States in
both private and public schools. Box 30.2 lists the purposes of

the YRBSS. Reports from the survey provide valuable
information that can help improve health education programs in
schools.
Injury Prevention
Injury prevention should be taught early in schools, and the
information should be age appropriate. For example, bicycle
safety, including the importance of wearing a helmet and the
proper use of backpacks, must be stressed beginning in
elementary schools. Safety on the schoolyard and playground is
also important for this age group, because approximately
200,000 children per year are injured on playgrounds in the
United States (U.S. Consumer Product Safety Commission,
2009). Motor vehicle safety should be included in programs for
adolescents who are beginning to drive. These motor vehicle
safety programs should include the hazards of distracted driving
(e.g. cell phones, texting), which are issues affecting all drivers.
Sports safety is particularly important among adolescents as
participation in sports continues to grow, especially among
girls. More than 3.5 million children younger than 14 years
receive medical treatment in emergency rooms each year for
sports-related injuries (Safe Kids USA, 2011). Injuries occur
most commonly on playgrounds, on athletic fields, and in
gymnasiums. Orthopedic injuries (e.g., strains, sprains,
fractures, and dislocations), dental injuries, neurological
problems (e.g., traumatic brain injury [TBI] and concussion),
ophthalmic injuries, cuts, abrasions, and bruises are frequently
seen. TBI accounts for more 20,000 of these injuries and
continues to be a significant concern for health care providers
and school nurses (Cheng et al., 2016).
Use of proper equipment should be mandatory for children and
adolescents participating in sports activities. Fitted mouth
guards, shin guards, pads, helmets, and other protective gear
should be required to prevent injury. Regular hydration and
frequent rest periods should be required to prevent heat-related
illnesses, especially during hot weather. Effective warm-up and
cool-down exercises should be encouraged to prevent muscle

strain. Schools that participate in aquatic sports should include
pool safety. The school nurse has a unique opportunity to work
with the athletic staff to promote these kinds of policies.
The sports physical is a good time for the school nurse to
counsel the student about the risk of health problems related to
physical activity. This is also an appropriate setting for the
nurse to question girls about menstrual irregularities and to ask
all students about their eating behaviors, feelings about their
weight, and history of musculoskeletal injuries. The nurse can
use this setting to teach the importance of stretching exercises
to help prevent injuries.
Many school districts have school safety committees that make
recommendations for sports-related safety. These committees
collect data on injuries, develop safety inspection policies, and
plan staff training and student education related to school
environmental factors. Nurses are vital members of school
health teams and committees from instituting injury prevention
programs to injury response on the athletic field.
Tobacco Use
For the past several decades, major concerns have been raised
about long-term health problems associated with adolescents’
use of tobacco, alcohol, and illegal substances. There is an
increased likelihood that these youthful abusers will ultimately
engage in other high-risk behaviors. Adolescent smoking has
been closely correlated with alcohol use and other drugs.
Smoking by young people can cause serious health problems,
such as heart disease; chronic lung disease; and cancers of the
lung, pharynx, esophagus, and bladder. Factors that have been
associated with youth tobacco use include low economic status,
peer pressure, smoking by parents, a perception that tobacco use
is the norm, low levels of academic achievement, exposure of
advertising, and history of aggressive behavior such as
membership in gangs (CDC, 2016).
Although there has been improvement over the last decades,
smoking remains a major problem in this country and is the
single leading preventable cause of death in the United States.

Cigarette smoking has declined significantly, but the usage of
other forms of tobacco has emerged; this includes electronic
cigarettes, hookah, pipes, bidis, flavored tobacco, and
smokeless tobacco (CDC, 2016). Prevention should be a priority
in youth
because 9 out of 10 cigarette smokers first tried smoking by 18
years of age (USDHHS, 2014). Of continued concern, it is
estimated that more than 25% of high school students in 2015
used some form of tobacco (CDC, 2016). Further, an estimated
3200 youth under the age of 18 try their first cigarette each day,
with an additional 2100 youth becoming daily smokers
(USDHHS, 2014). White high school students have the highest
rate of consumption of tobacco in various forms, at 24.0%,
followed by Hispanics at 23.9%, and blacks at 21.0%. Finally,
percentage rates for any tobacco product usage are 20.3% in
females and 30.0% in males (CDC, 2016).
Substance Abuse
The use of alcohol and other drugs is associated with problems
in school, injuries, violence, and motor vehicle deaths. All 50
states and the District of Columbia have outlawed the sale of
alcohol to anyone under the age of 21, yet it is still the most
commonly used and abused drug among children and
adolescents. In 2014, statistics show that 33% of 15-year-olds
and 60% of 18-year-olds had tried alcohol; thus use increased in
frequency as youths progressed in school (Substance Abuse and
Mental Health Services Administration, 2016). Furthermore,
approximately 17.7% of high school students reported they had
five or more drinks of alcohol in a row within a couple of hours
at least 1 day within the last 30 days (CDC, 2016).
Additionally, almost 32.8% reported having had at least one
drink of alcohol during the last 30 days (CDC, 2015). Alcohol
use is more prevalent among Hispanics (34.4%) and whites
(35.2%) than blacks (23.8%) (CDC, 2015).
The most commonly used illicit drug in the United States is
marijuana. In 2015, 38.6% of young people reported using

marijuana one or more times in their lives (CDC, 2015). A new
disturbing trend is the use of synthetic marijuana as known as
K2, Spice, fake weed, King Kong, or Moon Rocks, with 9.2% of
high school students reporting its use in 2015 (CDC, 2015).
The use of other illegal drugs in high school students includes
cocaine (5.2%), hallucinogenics (6.4%), Ecstasy (5.0%),
inhalants (7.0%), heroin (2.1%), methamphetamine (3.0%),
steroids (3.5%), and prescription drugs (opioids, depressants, or
stimulants) (16.8%) (CDC, 2015). Of significant concern is the
growing abuse of prescription drugs. Opioids (e.g., Vicodin or
OxyContin), depressants or antianxiety medications (e.g.,
Valium or Xanax), and stimulants (e.g., Ritalin or Adderall) are
the most commonly abused. Many times students obtain these
drugs from other family members who have been prescribed the
medication or from the illegal sale on the streets or through the
Internet.
The use of anabolic steroids has decreased somewhat among
high school students, declining from 3.6% in 2011 to 3.0% in
2015, but the issue should remain a concern to school health
nurses because of the number of athletes who abuse the drugs
(CDC, 2015). Many athletes believe that anabolic steroids will
produce an increase in strength and muscle mass and enhance
their performance. There are more than 100 different types of
anabolic steroids, and all require a prescription. Abuse or
improper use of anabolic steroids can result in severe problems,
including renal impairment or failure; liver cancer;
cardiovascular problems such as high blood pressure and
elevated cholesterol levels; and sexual changes such as
testicular shrinkage, clitoral enlargement, and accelerated
puberty (National Institute on Drug Abuse, 2016.
BOX 30.3 Teen Pregnancy
· • The U.S. teen birth rate is one of the highest among
developed countries.
· • 249,078 babies were born to teenagers aged 15 to 19
in 2014.

· • Black and Hispanic youth have a disproportionately
high rate of teen pregnancy.
· • Teen mothers are less likely to complete high
school.
· • Teen mothers are more likely to be single parents
and to live in poverty.
· • Birth rates among teenagers vary substantially from
state to state.
Data from Centers for Disease Control and Prevention: About
teen pregnancy, 2016.
https://www.cdc.gov/teenpregnancy/about/
Sex Education
A number of objectives of Healthy People 2020 address issues
of human sexuality and prevention of pregnancy, STDs, and
HIV. These issues are important for the nurse working with
older children and adolescents.
Many teens become sexually active at an early age, and despite
recent declines, pregnancy rates continue to be high (Box 30.3).
Data obtained from the YRBSS reveals a decrease from 47.4%
in 2011 to 41.2% in 2015 of adolescents in grades 9 through 12
who have had sexual intercourse (CDC, YRBSS, 2016).
Sex education in the school setting is a controversial topic.
Opponents of sex education believe that parents have the
responsibility for teaching this content to their children. Laws
in certain states prohibit or dramatically limit sex education in
public schools. However, 24 states and the District of Columbia
mandate that public schools teach sex education (National
Conference of State Legislatures, 2016). Proponents argue that
for many children sex education will not be addressed in the
home. If this information is not taught in schools, children may
receive inadequate or incorrect information from peers, media,
or other sources. Contrary to some concerns, there is no
research that concludes that sex education in the schools
increases sexual activity. According to the Future of Sex
Education Initiative (2012), the following seven topics are
considered fundamental to a comprehensive sex education

curriculum: anatomy and physiology, puberty and adolescent
development, identity (sexual orientation), pregnancy and
reproduction, STDs and HIV, healthy relationships, and
personal safety. School nurses have been caught in the center of
this controversy but historically have advocated for education
on normal human sexuality that encourages discussion in an
objective, nonjudgmental manner and in which students are free
to ask questions and receive correct answers.
Tattoos and Body Piercings
Tattoos and body piercings are a form of self-expression and
attention-seeking behavior. Their popularity has risen
dramatically in the last decade. The procedures are often done
at home, on the streets, or in parlors where sterile technique and
safety precautions are not practiced. Both hepatitis C and
methicillin-resistant Staphylococcus aureus have been linked to
tattoos and
body piercings. This fact presents an opportunity for the school
nurse to teach students the importance of making healthy
decisions on whether to have such procedures done and, if so,
under what conditions they will be performed.
Dental Health
One of the most common complaints of school-age children is
dental caries. There are numerous contributing factors,
including poor oral hygiene, lack of fluoridated water, and lack
of funds or insurance for dental care. More than half of children
have dental caries by the time they are 8 years of age. This
disease is more common in lower-income children, and
approximately 66% of those between the ages of 12 and 19 have
had tooth decay. Untreated cavities can greatly affect a child’s
quality of life and cause pain, absence from school, and
decreased self-worth (CDC, 2015). Proper brushing of teeth
should be taught along with good nutritional habits and the
importance of regular dental checkups. Children should also be
taught the relationship between high-sugar foods and dental
caries.

Physical Education
One of the major objectives of Healthy People 2020 is
improvement of health and fitness through regular physical
activity. Children today are less active than children in the past.
Daily enrollment in physical education classes among high
school students dropped from 42% in 1991 to 29% in 2013
(CDC, 2013). Children are becoming more sedentary as a result
of increased use of computers and television and decreasing
requirements for physical education. It was reported in 2011
that 31% of high school children used a computer 3 or more
hours a day and 32% watch television 3 or more hours a day
(CDC, 2012).
A sedentary lifestyle is associated with obesity, hypertension,
heart disease, and diabetes. Studies show that people who are
active have a better quality of life and outlive those who are
inactive. Habits in childhood are likely to continue into
adulthood, making it imperative that children are taught the
importance of being physically active at a young age. Studies
also show that children and adolescents who are physically
active have increased self-confidence and self-esteem and
decreased anxiety, stress, and depression. Regular physical
activity helps build and maintain healthy bones and muscles.
Physical education should focus on activities that children can
continue into their adult years, such as walking, swimming,
biking, and jogging. The educational content should change as
the child ages. For example, what may appeal to a young child,
such as playing on the playground with friends, is different
from what motivates an adolescent, such as competitive sports
and aerobic exercise. The CDC has made 10 recommendations
for the promotion of lifelong physical activity (Box 30.4).
Health Services
Health care provided in schools includes preventive services
such as immunizations and health screenings. This component
of a comprehensive school health program may also involve
emergency care, management of acute and chronic health
conditions, appropriate referrals, health counseling, education

about healthy lifestyles, and medication administration.
BOX 30.4 Guidelines for School Programs: Promoting Healthy
Eating and Physical Activity
· • Use a coordinated approach to develop, implement,
and evaluate healthy eating and physical activity policies and
practices.
· • Establish school environments that support healthy
eating and physical activity.
· • Provide a quality school meal program and ensure
that students are offered only appealing, healthy food and
beverage choices outside the school meal program.
· • Implement a comprehensive physical activity
program with quality physical education as the cornerstone.
· • Implement health education that provides students
with the knowledge, attitudes, skills, and experiences needed
for healthy eating and physical activity.
· • Provide students with health, mental health, and
social services to address healthy eating, physical activity, and
related chronic disease prevention.
· • Partner with families and community members in
the development and implementation of healthy eating and
physical activity policies, practices, and programs.
· • Provide a school employee wellness program that
includes healthy eating and physical activity services for all
school staff members.
· • Employ qualified persons and provide professional
development opportunities for physical education; health
education; nutrition services; and health, mental health, and
social services staff members, as well staff members who
supervise recess, cafeteria time, and out-of-school-time
programs.
From Centers for Disease Control and Prevention: School health
guidelines to promote healthy eating and physical activity,
MMWR Recomm Rep 60(RR-5):1–76, 2011.
www.cdc.gov/mmwr/pdf/rr/rr6005.pdf.

Immunizations
Immunizations are a vital component of routine health care,
providing long-lasting protection against many diseases.
Vaccine-preventable deaths are at record-low levels. Many
communicable diseases have been reduced by more than 99% as
a result of immunizations. Undervaccination of children,
especially those in large urban areas, is a concern because of
the potential for disease outbreaks.
All states now require proof of immunization status or evidence
of immunity before a child can enter school. Certain exceptions
based on religious and philosophical beliefs or medical
contraindications may apply. The school nurse plays an
important role in verifying compliance with immunization
requirements and in educating children and parents about the
benefits of immunization. See the CDC website
(https://www.cdc.gov/vaccines/schedules/hcp/index.html) for
current immunization schedules.
Health Screenings
Many children in the United States are not appropriately
screened for certain treatable conditions. Impaired vision and
hearing can result in poor academic performance, slowed
emotional development, and stress-related disorders. Early
identification and treatment of these problems is highly
effective and less costly. Vision and hearing screenings are
provided at most schools according to a schedule set by the
state or school district. These screenings usually occur upon a
child’s initial entry to school and at least once during
elementary, middle, and high school. Children and adolescents
may need to be screened
more often on the basis of family history, developmental delays,
recurrent ear infections, or exposure to loud noise.
Vision screening is required in most states, with referrals as
needed. The standard Snellen vision chart is the usual screening
tool. Screening for strabismus is a nursing responsibility, and
this condition must be identified and treated early to prevent

amblyopia. If left untreated, amblyopia may result in loss of
vision. Referral to an eye specialist is a critical component of
all abnormal eye examination results.
Scoliosis or postural screening should be done to identify spinal
deviations in an effort to prevent secondary problems. Spinal
problems may lead to cosmetic, functional, or emotional
problems. Scoliosis screening in the school consists primarily of
a visual inspection of the back. The American Academy of
Pediatrics and the American Academy of Orthopedic Surgeons
recommend screening of all girls at 10 and 12 years and boys
once at either 13 or 14 years (Hresko et al., 2015).
The assessment of high blood pressure during childhood is
important in identifying children who have hypertension and
who will benefit from early intervention and follow-up.
Vascular and end-organ damage from hypertension can begin in
early childhood. Periodic blood pressure measurements are
inexpensive and should be performed routinely for all children.
Other periodic screenings may be mandated by various state or
district regulations. These include body mass index (BMI)
(height and weight) and dental screenings.
The Children’s Health Insurance Program is a national program
designed for children of families who earn too much money to
qualify for Medicaid but cannot afford the high cost of health
insurance. Medicaid-eligible children are guaranteed access to
comprehensive health care services and routine dental
examinations. Medicaid created the Early and Periodic
Screening, Diagnosis, and Treatment (EPSDT) service because
of the large number of uninsured children. EPSDT, a
comprehensive child health program for the uninsured under the
age of 21, includes health education and periodic screening.
Services provided under the EPSDT program are often
performed through the public health offices in each state, but
may occur in community health clinics and schools. Screening
services must include a comprehensive health and
developmental history, an unclothed physical examination,
immunizations and laboratory testing that are age appropriate,

and lead toxicity screenings (Centers for Medicare and
Medicaid Services, 2017).
Emergency Care
Schools are a common site of injuries ranging from minor
scrapes, bruises, and fractures, to more severe life-threatening
events such seizures, head injuries, severe asthma attacks, and
mass casualty incidents. Injuries may occur in school buildings
or classrooms or during physical education classes or athletic
events. Emergencies can include natural events, such as
hurricanes, tornadoes, and earthquakes, or manmade disasters,
such as hazardous material spills, fires, and acts of terror. Basic
first aid equipment should be available in all schools. The
school nurse must be knowledgeable about standard first aid and
certified in cardiopulmonary resuscitation and use of an
automated external defibrillator. The school nurse must also be
responsible for the development of a school emergency plan that
provides school staff with a guide to facilitate quick response in
case of a student or school emergency.
Care of the Ill Child
The school nurse is responsible for monitoring the health of all
students. For students with acute or chronic illnesses,
administration of medications or treatments may be necessary.
The nurse is often required to assess an ill child to determine
the type of illness or health problem and develop a management
plan. Two commonly encountered chronic illnesses are asthma
and diabetes.
In 2014, 8.6% of U.S. children younger than 18 years had
asthma, which was most prevalent among poor children (16.4%)
and non-Hispanic black children (18.4%) (CDC, 2014). Asthma
is one of the most common chronic childhood conditions,
causing more than 4.6 million people to miss more than 1 day of
school or work (CDC, 2011). Because asthma is so prevalent, it
is recommended that school-based support exists for children
who have it. Actions undertaken by some schools across the
country include immediate access to asthma medications,
development and implementation of asthma action plans, and

student and staff education on asthma. An assessment tool has
been developed to determine how well schools assist children
with asthma (Box 30.5). Answers to all the questions in the
assessment tool should be “yes.” “No” answers indicate that
students may not be in an environment conducive to asthma
control.
According to the American Association of Diabetes Educators
(AADE, 2016), diabetes is prevalent in school-age children,
affecting around 190,000 people younger than 20 years. Most
cases of diabetes in this cohort is type 1, but type 2 diabetes is
being diagnosed with increasing frequency in children. Type 2
diabetes in youth is projected to increase by 49% in the next 40
years, and the number of children diagnosed with type 1
diabetes is expected to increase 23%. The figures are
disproportionately larger in minority populations. Childhood
obesity and the decline in physical activity are considered major
factors in this development (American Diabetes Association
[ADA], 2012). In general, teachers are inadequately prepared to
care for children with diabetes and must rely on the school
nurse. Children should be able to participate in their care to the
extent that they are able (ADA, 2012). With the growing
number of children who have diabetes, it is imperative that the
nurse recognize the signs and symptoms of hypoglycemia and
hyperglycemia in order to assist children in the monitoring of
glucose levels and the administration of insulin or glucagon.
The ADA has specific recommendations based on age, as shown
in Box 30.6.
Medication Administration
Administration of medications is a service provided almost
universally by school districts across the country. The use of
medications by school-age children has increased over the last
several years, allowing many children to attend school despite
serious health problems.
Medication administration in the schools is a serious
undertaking. Issues facing the school nurse include safety,
monitoring of both therapeutic and side effects, proper

documentation, confidentiality, and ongoing communication
with the student and family. Only those medications considered
necessary are administered at school.
BOX 30.5 How Asthma-Friendly Is Your School? Checklist
Children with asthma need proper support at school to keep
their asthma under control and be fully active. Use the
following questions to find out how well your school assists
children with asthma.
□ Yes□ No
Is your school free of tobacco smoke at all times, including
during school-sponsored events and on school buses?
□ Yes□ No
Does the school maintain good indoor air quality? Does it
reduce or eliminate allergens and irritants that can make asthma
worse? Check if any of the following are present:
□ Cockroaches
□ Dust mites (commonly found in humid climates in pillows,
carpets, upholstery, and stuffed toys)
□ Mold
□ Pets with fur or feathers
□ Strong odors or fumes from art and craft supplies, pesticides,
paint, perfumes, air fresheners, and cleaning chemicals
□ Yes□ No
Is there a school nurse in your school all day, every day? If not,
is a nurse regularly available to help the school write plans and
give the school guidance on medicines, physical education, and
field trips for students with asthma?
□ Yes□ No
Can children take medicines at school as recommended by their
doctor and parents? May children carry their own asthma
medicines?
□ Yes□ No
Does your school have a written, individualized emergency plan
for teachers and staff in case of a severe asthma episode
(attack)? Does the plan make clear what action to take under

different emergency situations such as fire, weather, or lock-
down? Whom to call? When to call?
□ Yes□ No
Does someone teach school staff about asthma, asthma action
plans, and asthma medicines? Does someone teach all students
about asthma and how to help a classmate who has it?
□ Yes□ No
Can students actively participate in physical education class and
recess? (For example, do students have access to their medicine
before exercise? Can they choose modified or alternative
activities when medically necessary?)
If the answer to any question is “no,” students in your school
may be facing obstacles to asthma control. Uncontrolled asthma
can hinder a student’s attendance, participation, and progress in
school. School staff, health professionals, and parents can work
together to remove obstacles and promote students’ health and
education.
From National Heart, Lung, and Blood Institute, National
Asthma Education and Prevention Program, NAEPP School
Asthma Education Subcommittee: How asthma friendly is your
school? 2008.
www.nhlbi.nih.gov/health/public/lung/asthma/friendly.pdf
BOX 30.6 Expectations of the Child With Diabetes
Toddler and Preschool Age
· • The child should be able to determine which finger
to prick.
· • The child can usually choose an injection site.
· • The child is generally cooperative.
Elementary School Age
· • The child should be able to assist in all diabetes
tasks at school.
· • The child is usually able to perform his or her own
fingerstick glucose monitoring.
· • The child can administer his or her own insulin with

supervision.
· • The child is usually able to let an adult know when
he or she is experiencing a hypoglycemic episode.
Middle School and High School Age
· • The child should be able to perform self-monitoring
of blood glucose.
· • Most children should be able to administer their
own insulin with supervision; adolescents should be able to
administer insulin without supervision.
· • All children may need assistance with blood glucose
testing when the glucose level is low.
Data from American Diabetes Association: Diabetes care in the
school and day care setting, Diabetes Care 35:S76–S80, 2012.
The following guidelines from NASN (2017) should be included
in school medication policies:
· • Delegation (including training and supervision of
unlicensed assistive personnel)
· • Medication orders
· • Prescription and over-the-counter medications
· • Proper labeling, storage, disposal, and
transportation of medication
· • Documentation of medication administration
· • Rescue and emergency medications
· • Off-label medications and investigational drugs
· • Complementary and alternative medications
· • Psychotropic medications and controlled substances
· • Medication doses that exceed manufacturer’s
guidelines
· • Student confidentiality
Medications commonly given in schools include analgesics and
antipyretics (e.g., acetaminophen [Tylenol] or ibuprofen
[Advil]), antacids, antitussives, anticonvulsants, antiemetics
and antidiarrheals, antifungals, antihistamines, and antibiotics.
Medications used to treat attention-deficit hyperactivity

disorder (ADHD) are among the most commonly administered.
In a report released in 2015, 9.5% of children in the United
States between 4 and 17 years were diagnosed with ADHD, and
this number appears to be increasing (Pastor, 2015).
Alternative and complementary medicine includes practices and
products outside the realm of conventional medicine.
Medication administration policies should exist that reflect
local and state laws that address these products. The request for
the administration of any of these medications provides the
nurse with an excellent health teaching opportunity.
School nurses must be aware of medications that are being self-
administered on school grounds and must provide education as
needed to both children and parents. Rescue medications such as
albuterol for asthma or an EpiPen for a child with a severe
allergic reaction must be administered quickly to affect asthma
symptoms, and the nurse must be familiar with its expected
effects to properly assist the child who needs it. It is now legal
in all 50 states for students to carry and self-administer asthma
medications (NASN, 2017).
TABLE 30.2
Overview of Increase in Number of Students With Disabilities∗
Type of Disability
1976–1977
1990–1991
2000–2001
2009–2010
2013–2014
All disabilities
8.3
11.4
13.3
13.1
12.9
Specific learning disabilities
1.8
5.2

6.1
4.9
4.5
Speech or language impairments
2.9
2.4
3.0
2.9
2.7
Developmental delays
—
—
0.4
0.7
0.8
Emotional disturbance
0.6
0.9
1.0
0.8
0.7
Hearing impairment
0.2
0.1
0.2
0.2
0.2
Orthopedic impairments
0.2
0.1
0.2
0.1
0.1
Other health impairments
0.3
0.1

0.6
1.4
1.6
Visual impairments
0.1
0.1
0.1
0.1
0.1
Multiple disabilities
—
0.2
0.3
0.3
0.3
Autism and related disorders
—
—
0.2
0.8
1.1
∗ Children age 3 to 21 years served in federally supported
programs for the disabled by type of disability: selected years
1976– 1977 through 2013–2014.
From National Center for Education Statistics: NCES fast facts:
students with disabilities, 2016.
https://nces.ed.gov/fastfacts/display.asp?id=64
Children With Special Health Needs
In 1976, Public Law 99-142 was enacted, giving all students,
including those who are severely handicapped, the right to
public education in the least restrictive environment possible,
regardless of mental or physical disabilities. The Education for
All Handicapped Children Act of 1973 and the subsequent
Individuals with Disabilities Education Act (IDEA) of 1990
enhanced the opportunities for children previously served in

acute care and long-term care settings to have access to public
education. Children affected by these laws include those who
are hearing impaired, mentally challenged, multihandicapped,
orthopedically impaired, “other” health impaired (e.g., chronic
or acute health problems such as a heart condition or epilepsy),
seriously emotionally disturbed, speech impaired, visually
handicapped, or who have a specific learning disability.
The development of health care services and technology has
enabled students whose conditions may have prevented them in
the past from leaving an institution or controlled environment to
attend public school. Many of these children need nursing
services of varied types (e.g., tube feedings, suctioning,
catheterization) to continue their progression in school. Public
Law 94-142 requires school nurses to screen or identify children
in need of special education and related services and to
participate in the development of an interdisciplinary
individualized education program (IEP) that includes
educational goals and specific services to be provided. The
nurse is also responsible for the development of an
individualized health care plan (IHP) for all students requiring
continuous nursing management while at school. Table 30.2
gives an overview of the increase in the number of students with
disabilities.
Student Records
Health records are maintained for all students according to
individual school district policy. At a minimum, student health
records should include immunization status, pertinent history,
results of screenings and examinations, and IHPs. The Family
Educational Rights and Privacy Act, a strong privacy protection
act, protects student education and health records. Student
health records should be afforded the same level of
confidentiality as that given to clients and patients in other
settings (i.e., sharing confidential information with others
without approval is considered unethical and improper except in
emergency situations).
The Health Insurance Portability and Accountability Act of

1996 (HIPAA) was instituted in 2003. A major component of
HIPAA is ensuring confidentiality of personal health
information. Public schools that provide health care services
fall under HIPAA regulations. Private schools that do not
receive federal funding but engage in HIPAA-related activities
are also governed by this act.
Delegation of Tasks
Not every school has a full-time nurse available on site. A nurse
may be assigned to three or four schools, resulting in delegation
of certain tasks to unlicensed personnel. Each state’s Nurse
Practice Act stipulates which procedures may be delegated. The
responsibility for assessment, diagnosis, goal setting, and
evaluation may never be delegated. When tasks are delegated,
the nurse must provide appropriate education, written
procedures, and ongoing supervision and evaluation of the
caregivers.
Nutrition
School-age children are undergoing periods of rapid growth and
development and have complex nutritional needs. They must eat
a variety of foods to meet their daily requirements. Diets should
include a proper balance of carbohydrates, protein, and fat, with
sufficient intake of vitamins and minerals. Children and
adolescents share a well-known preference for junk food (Box
30.7), and their diet is often high in fat and sugar and frequently
consists of fast-food items, such as hamburgers and French
fries, instead of fruits and vegetables. Skipping meals,
especially breakfast, and eating unhealthy snacks contribute to
poor childhood nutrition. Identifying nutritional problems,
counseling, and making appropriate referrals are important in
the school setting. The school nurse should consider cultural
influences on diet when teaching students and assessing their
nutritional status.
Poor nutritional status is closely associated with poverty.
Federally funded programs such as the School Breakfast
Program and National School Lunch Program were initiated to
ensure that all children have access to these meals during the

school day.
Eating Disorders
It is imperative that the school nurse recognize the association
between feelings of inadequacy and unhealthy eating practices
in adolescents and young people. These self-perceptions begin
early in life; therefore education and counseling must begin in
elementary school. Prevention should concentrate on
eliminating misconceptions surrounding nutrition, dieting, and
body composition and should stress optimal health and personal
performance. Outside influences such as social media, celebrity
admiration, commercials, and advertisements make this a
serious problem.
BOX 30.7 Vending Machine Food Choices
In 2004, the National Association of School Nurses addressed
the issue of unhealthy foods found in school vending machines
and sold in school fundraising projects. The organization
specifically resolved that schools should provide healthy food
choices in school vending machines and for sale in fundraising
projects.
Data from National Association of School Nurses: Resolution:
vending machines and healthy food choices in schools, 2004.
www.nasn.org.
School nurses must also be aware of eating disorders and
related risk factors. Anorexia, bulimia, and binge eating are the
three most common eating disorders, and anorexia is ranked
number three in terms of chronic disorders in adolescents
(NIMH, 2016). Binge eating is defined as recurrent, out-of-
control eating of large amounts of food whether a person is
hungry or not. Anorexia is a severely restricted intake of food
based on an extreme fear of weight gain. Literature has shown
that anorexia is multifactorial, seen primarily in females, and
often correlated with family dysfunction or a history of sexual
abuse. Bulimia is a form of anorexia characterized by a chaotic
eating pattern with recurrent episodes of binge eating followed
by purging. Health consequences of eating disorders may

include reduction of bone density, severe dehydration, tooth
decay, and potentially fatal electrolyte imbalances.
Female Athlete Triad
The “female athlete triad” is a syndrome consisting of eating
disorders, amenorrhea, and osteoporosis. Pressure to attain a
particular body shape or weight considered desirable in a
selected sport may put the female athlete at risk for
development of this disorder. The triad is a complex problem
with psychological and physiological factors. It can result in
menstrual irregularities, premature osteoporosis, and decreased
bone mineral density; if taken to the extreme, it can become life
threatening.
Obesity
Obesity is the fastest-rising public health concern in the nation
and will likely overtake tobacco use as the single leading
preventable cause of death. The obesity rate has more than
doubled in children and tripled in adolescents over the past
three decades. Today one in five school-aged children (ages 6 to
19) are considered obese (CDC, 2016). Statistics show that
obese children and adolescents are more likely to become obese
adults. Obesity and its prevention or treatment must be of
concern to the school nurse (CDC, 2013).
Although many of the underlying causes of obesity are not well
understood, several contributing factors have been identified;
they include reduced access to and affordability of nutritious
foods, decreased physical activity, and cultural and genetic
influences. Obesity is associated with development of diabetes,
dyslipidemia, hypertension, and other disorders, such as
osteoarthritis, sleep apnea, different cancers, and cholelithiasis.
In addition, obesity may result in social and quality-of-life
impairment, and obese children often have low self-esteem and
may be labeled by their peers and ridiculed (CDC, 2013). The
school nurse should determine the BMI for all adolescents. A
BMI greater than the eighty-fifth percentile for age and gender
indicates the need for further assessment and referral. To be
successful, the treatment of obesity must begin early and must

be multifaceted. Some of the solutions include improved health
education related to nutrition and dietary behavior, increased
physical activity and physical education programs, healthier
school environments, and better nutrition services.
Nutritional Education Programs
Nutritional education is essential and must include parents,
teachers, and the child. Children need to know the basics of
good nutrition, how to make healthy snack choices, and the
importance of balancing physical activity with food intake.
Obesity, dental caries, anemia, and heart disease can be reduced
or prevented with proper education and lifestyle changes. In
addition, all adolescents and school-age children should receive
counseling regarding intake of saturated fat.
The United States Department of Agriculture (USDA) Food and
Nutrition Service (FNS) provide nutritional education for food
service educators, professionals, parents, and child care
providers, The USDA and FNS have a number of resources,
including MyPlate, Team Nutrition, Let’s Move, and SNAP-Ed
Connection. These programs focus on healthy nutritional
choices and health promotion and disease prevention topics in
school and child care settings. Comprehensive school-based
nutrition programs and services should be provided to all
students. The ultimate goal of these efforts is that children will
make healthy nutritional choices both inside and outside the
school setting.
Counseling, Psychological, and Social Services
The mental health of a child or adolescent is affected by
physical, economic, social, psychological, and environmental
factors. Children, like adults, often hide problems from others.
They may see problems as a sign of weakness or as a lack of
control. Children may also be trying to protect themselves or
someone they love and so do not seek help, with tragic results.
Promotion of mental health and reduction or removal of threats
to mental health is important to children and adolescents. This
can be an enormous challenge for school nurses as mental health
is difficult, yet essential, to assess.

Children and teens often struggle with depression, substance
abuse, conduct disorders, self-esteem issues, suicidal ideation,
eating disorders, and underachievement or overachievement.
They may also have to cope with physical or mental abuse,
chronic health conditions, or pregnancy. Common warning signs
of stress in children are presented in Box 30.8. Drugs and
alcohol can enter a child’s life as early as elementary school.
Many children live in single-parent households with little social
or economic support. They may not have enough to eat or a
safe, warm place to sleep, yet are expected to come to school
each day ready to learn. Services aimed at helping children cope
with these problems are often lacking or too costly for many
families.
Ethical Insights
An Ethical Dilemma: What Would You Do?
You are working as the school nurse in a rural high school when
Grace, a 15-year-old female student, enters the clinic. Grace
appears very worried, and, after several hesitant starts, she
begins to cry and tells you that she is sexually active with a 17-
year-old senior. She goes on to tell you that she has missed her
last period and that her home pregnancy test result was positive.
She states that she is afraid to tell her parents because she feels
that they will be very disappointed in her and because she is
afraid of what her father will do. She asks you where she can go
to get an abortion. You speak with Grace for quite a while and
encourage her to speak with her parents. She leaves the clinic a
little more composed and promises you that she will think about
what you have said. The next day Jenny, Grace’s mother, comes
into the clinic and asks to speak with you. She confides that she
is worried about Grace and asks whether you know what is
going on with her child. What would you do in this situation?
Although maintaining confidentiality and a professional
relationship respectful of the student’s wishes is vital, state
laws and school district policies determine what a school nurse

may do, and in some cases is required to do, when providing
care to minor children. In order to deal with personal and
sensitive information such as described here, the school nurse
should be well versed in relevant laws and policies and should
follow them. When in doubt, contact a supervisor.
BOX 30.8 Warning Signs of Stress
· • Problems eating or sleeping
· • Use of alcohol or other substances (e.g., sedatives,
sleep enhancers)
· • Problems making decisions
· • Persistent anger or hostile feelings
· • Inability to concentrate
· • Increased boredom
· • Frequent headaches and ailments
· • Inconsistent school attendance
The nurse or teacher may be the only stable adult in a child’s
life who will listen without being judgmental. Therefore one of
the most important roles of the school nurse is to act as
counselor. Children may come to the school nurse with various
vague complaints, such as recurrent stomachaches, headaches,
and history of sexually promiscuous behavior, and the nurse
must look beyond the initial complaint to identify underlying
problems.
Major depressive disorders often have their onset in
adolescence and are associated with an increased risk of
suicide. In 2014 suicide was the second leading cause in both
the 10- to 14-year and 15- to 19-year age groups (CDC, 2014).
Suicide attempts are more common than completed suicides. A
2015 survey of students in grades 9 through 12 showed that
8.0% attempted suicide in the preceding year and 17% seriously
considered suicide (CDC, 2015). The nurse and other school
personnel must be on the alert for suicide clusters that are often
known to follow a successful suicide. Adolescents may
approach school nurses and other school professionals for help
before a suicide attempt. The call for help may be subtle and not

recognized as such. Therefore it is important for the school
nurse to be cognizant of the warning signs associated with
suicide and to recognize and refer at-risk adolescents to
appropriate mental health professionals (Box 30.9).
Unfortunately, a large number of children are victims of abuse.
Physical and psychological abuse and neglect are usually a
result of many interacting factors, such as poverty, social
isolation, and drug and alcohol abuse. School nurses and other
school personnel are mandated to report suspected cases of
child maltreatment and neglect. The nurse must be alert to
subtle changes in behavior or physical appearance that may
point to abuse. Box 30.10 outlines some of the signs and
symptoms of child maltreatment.
BOX 30.9 Truths About Adolescent Suicides
· • Most adolescents who attempt suicide are
ambivalent and torn between wanting to die and wanting to live.
· • Any threat of suicide should be taken seriously.
· • Warning signs usually precede a suicide attempt;
they may include depression, substance abuse, decreased
activity, isolation, and appetite and sleep changes.
· • Suicide is more common in adolescents who are
dealing with bisexuality or homosexuality without support or in
a hostile school environment.
· • Education concerning suicide does not lead to an
increased number of attempts.
· • Females are more likely to consider or attempt
suicide, and males are more likely to complete a suicide
attempt.
· • One suicide attempt is more likely to result in a
subsequent attempt.
· • Sixty percent of completed suicides in children and
adolescents are committed with guns.
· • Most adolescents who have attempted or completed
suicide have not been diagnosed as having a mental disorder.
· • Suicide affects all socioeconomic groups.

BOX 30.10 Possible Signs of Abuse and Neglect
Physical Abuse
· • Has unexplained burns, bites, bruises, black eyes, or
broken bones
· • Is wary of adult contact
· • Appears frightened of parents or other relatives and
cries when it is time to go home
Neglect
· • Is frequently absent from school
· • Steals food or money
· • Lacks adequate medical or dental care
· • Appears dirty or disheveled or is underweight
· • Does not have proper seasonal clothing
Sexual Abuse
· • Has difficulty walking or sitting
· • Reports new onset of nightmares or bedwetting
· • Refuses to change into gym attire or participate in
physical activities
· • Runs away from home
· • Becomes pregnant or has a sexually transmitted
disease
Emotional Abuse
· • Exhibits changes in behavior, such as acting out or
extreme passivity
· • Exhibits delay in either physical or emotional
development
· • Has attempted suicide
· • Exhibits inappropriate adult or infantile behavior
Data from Child Information Gateway: What is child abuse and
neglect? Recognizing the signs and symptoms, 2013.
https://www.childwelfare.gov/pubs/factsheets/whatiscan.cfm.

In cases of child abuse or neglect, the school nurse may help the
child learn problem solving, coping mechanisms, and steps to
build self-esteem. The role of the nurse may extend outside the
school campus. The nurse may need to work closely with
families and social services to develop an appropriate health
plan for a particular child.
Healthy School Environment
A healthy school environment is one in which distractions are
minimized and that is free of physical hazards and
psychological health risks. The NASN believes that all students
and staff have an inherent right to learn and work in a healthy
school environment and that the school nurse can “assess the
learning environment for risk factors, educate the community on
the impact of environmental exposure, and advocate for the
need to address environmental pollution issues” (NASN, 2014).
Violence
Violence is a major public health problem because it threatens
the health and well-being, both physical and psychological, of
many children and adolescents. According to the U.S.
Department of Justice, Bureau of Justice Statistics (2016),
during the 2014 school year, students were victims of 850,100
nonfatal victimizations at school, including 363,700 thefts and
486,400 violent crimes. Further, during the 2012–2013 school
year, 31 homicides occurred at school in K–12 schools (CDC,
2016). In high school–aged youths, 7.8% of students reported
they had been in a physical fight in the last year, and 5.6%
stated that they did not attend school for one or more days
because they felt unsafe (CDC, 2016).
In recent years, there have been a number of shootings and
other acts of serious violence in schools. The CDC (2016)
reported that 4.1% of children admitted to having carried a
weapon at least 1 day out of the last 30 and that 6.0% had been
threatened or injured with a weapon on school property within
the last year. The school shooting at Columbine High School in
Littleton, Colorado, in 1999 was probably the first time that
people in this country realized how unsafe schools could be.

More recently, the mass shooting, in Newtown, Connecticut,
killed 20 children and six adults, making it the nation’s worst
K–12 school shooting.
School nurses and other school personnel should be aware of
risk factors and signs that could indicate a tendency to violence.
Factors common in those who commit violent acts in school
include being male and having a history of being ostracized or
bullied in school. Media influences such as movies and video
games that desensitize the impact of violence are being studied
more closely as a possible cause of increased violence among
children and adolescents. Children involved in school shootings
often have a need for instant gratification, have easy access to
guns, and may have a history of discipline problems.
Although the number of students who commit violent acts is
small, these random acts are frightening, and school officials
struggle with ways to prevent their occurrence and to recognize
the signs of troubled youth. Violence prevention programs
should begin in elementary schools. Children who exhibit
aggressive behavior in elementary school are more likely to
exhibit antisocial and violent behavior as adolescents and
adults. Programs should target stress management, conflict and
anger resolution, and personal and self-esteem development.
Nurses should use data collected through the YRBSS and other
local data as a means of assessment when developing violence
policies and prevention programs in the school and community.
Additionally, nurses should initiate and participate in research
that examines the complex developmental, social, and
psychological factors surrounding violence.
Terrorism
Schools may not be the primary target in an act of terrorism, but
they will be affected. Events following the September 11, 2001,
terrorist attack illustrate potential problems facing schools,
which may include fear and panic among students, teachers, and
parents and anxiety among those directly affected.
Every school is expected to have an emergency management
plan. In fact, many states mandate that schools develop plans to

address the potential threat of a terrorist attack or natural or
manmade disaster. School nurses must be prepared to act after
any form of terrorism has occurred. The school nurse has an
important role as a potential first responder in any emergency
situation and should be an active participant in planning and
policy development.
Health Promotion for School Staff
Although specific numbers vary, it is estimated that schools in
the United States employ more than 5.5 million teachers and
other employees. Health promotion programs at the work site
have beneficial results, including positive effects on blood
pressure control, daily physical activity, smoking cessation,
stress management, and weight control. Staff who participate in
health promotion programs increase their knowledge and
positively change their attitudes and behaviors relative to
smoking practices, nutrition, physical activity, stress, and
emotional health. Health promotion programs improve morale,
reduce job stress and absenteeism, and heighten interest in
teaching health-related topics to students. School nurses play an
important role in all levels of prevention through assessment,
planning, intervention, and evaluation. The school nurse can
assist the faculty and staff by giving workshops on exercise and
nutrition, screening for increased blood pressure, and
establishing weight management programs.
Family and Community Involvement
School nurses are often asked to provide health education to
family, parents, and the community on a variety of topics, such
as sexuality, STDs, health promotion, communicable diseases,
and substance abuse. Health education in the community
consists of programs that are designed to positively influence
parents, staff, and others in matters related to health. School
nurses are a resource in the community and can take a
leadership role in developing programs that positively affect the
community. School nurses may also serve as consultants and
advocates for other community health programs.
Programs that engage the parents in school activities should be

based on community needs and resources. Studies show that
students who have parental support are more successful,
experience less emotional distress, eat healthier, and are more
actively engaged in learning. School nurses can promote
parental
involvement through the establishment of clear communication,
involving parents as volunteers and including them in the
planning of health-related events at schools. The nurse must
also recognize that an increasing number of children are being
raised in nontraditional families—single parents, grandparents,
gay or lesbian couples, and interracial couples. When
addressing issues with families, the nurse cannot let personal
feelings alter the plan of care and must be aware that what
worked with one family situation will not necessarily work for
another.
School nurses need to understand the needs of families and how
these needs may affect children in the school setting. The Annie
E. Casey Foundation (AECF) looks at some of these key needs
using the KIDS COUNT Index. The index looks at four domains
that kids need in order to thrive: 1) economic well-being, 2)
education, 3) health, and 4) family and community. Using these,
the AECF measures the status of child well-being at both state
and national levels. In 2016, Minnesota ranked first among all
states in overall child well-being, with Mississippi coming in
last (AECF, 2016). During the past 6 years, there has been
progress in some of the domains of child well-being (health and
education) but setbacks in others (economic well-being, family,
and community).
Nurses should become adept at working in the public sphere by
increasing their visibility and becoming skilled in working with
the media and legislators. The media can be useful in assisting
school nurses with health education advocacy.
Active Learning

· 1. Explain how the Healthy People 2020 objectives
can be used to shape school-based health care.
· 2. Log on to one of the websites for school nurses
such as http://www.schoolnurse.com/ or https://www.nasn.org/
and review the many resources available.
· 3. Interview a member of the local school board about
controversial subjects in health education (e.g., sex education).
· 4. Review the most common diseases and reported
injuries in school-age children in your area. Develop a plan for
how the school and the community can work together to
decrease their incidence.
· 5. Interview the parents of several school-age
children. Ask what health services they would like to see
provided in the school setting.
· 6. Arrange with the principal of a local school to have
a discussion session with children in a particular grade level.
Ascertain what their eating habits are and then develop a class
that can enhance healthy eating.
School Nursing Practice
School nursing is a specialty practice. School nurses need
education in specific areas, such as growth and development,
public health, mental health nursing, case management, program
management, family theory, leadership, and cultural sensitivity,
to effectively perform their roles. They must be prepared to
work with children of all ages and cultures and under variable
circumstances. The nurse must also keep abreast of issues
affecting children and must participate in research that explores
and expands the role. The school nurse’s practice is relatively
independent and autonomous, even though the school nurse
functions as a member of an interdisciplinary team. For entry
into school nursing, it is recommended that nurses hold a
minimum of a bachelor’s degree. The school nurse must be able
to identify and access professional development opportunities in
order to maintain competency in the care of children and
adolescents.
School nurses function in many roles. Among these are care

provider, student advocate, educator, community liaison, and
case manager. Additional skills needed by school nurses include
the ability to supervise others, to practice relatively
independently, and to delegate care. The American Nurses
Association developed competencies relevant to school nurses
and updated them in 2011. School Nursing: Scope & Standards
of Practice (3rd ed) can be purchased at
https://portal.nasn.org/members_online/members/viewitem.asp?i
tem=S001&catalog=MAN&pn=1&af=NASN.
The school setting is a perfect place to conduct research on how
children adapt to life transitions such as divorce, illness or
death of a loved one, illness of either themselves or a peer, and
domestic violence. The health-related behaviors of the young
are a rich source of research opportunities. The school nurse
must be aware of and interested in participating in different
research studies.
Research Highlights
Research Priorities for School Nursing
The National Association of School Nursing (NASN) has
identified critical areas for needed research in which there is no
evidence supporting or identifying best practices and the cost-
effectiveness of nursing practice in school (NASN, 2016). These
critical areas are:
· • Diabetes and Asthma: Determine the impact of
school nurse interventions on students managing their chronic
conditions in the school environment.
· • Identified School Nurse–Sensitive Indicators:
Determine the impact of school nurse interventions on issues
such as attendance, medication administration accuracy,
immunization rates, seat time, or health office visits.
· • Cost–Benefits Analysis: Conduct analysis of the
various interventions used by the school nurse with regard to
prevention services, emergency room visits, student safety, and
care coordination.
· • Current Models of School Nurse Practice: Evaluate

registered nurse (RN) practice on campus versus an RN
managing multiple campuses and the impact(s) on student
health, safety, and academics.
Additionally, Gordon and Barry (2006) surveyed 263 school
nurses to identify what the nurses believed to be the top
research priorities for the specialty. Ten areas were identified as
being priority research topics. These priority areas, and
examples for each, are presented here:
· • Obesity/Nutrition: Nutrition and weight-loss
counseling programs, eating disorders, obesity in children and
teens, important of exercise
· • Legal/Ethical Issues: Legal liability when
delegating to nonmedical personnel, ethical issues related to
children with Do Not Resuscitate orders, confidentiality,
HIPAA mandates
· • Emergencies: Emergency preparedness,
administering epinephrine autoinjectors (EpiPens) in school,
standing orders for emergencies
· • Health Education: Effective curricula for health
promotion on hot topics (drugs, sexual activity, nutrition,
exercise)
· • Absenteeism/Attendance: The school nurse’s impact
on student attendance, impact of absenteeism on educational
success, strategies to decrease absenteeism
· • Injuries: Playground safety, sports injuries
· • Health Services: Funding of school health services
by using matching reimbursement (Medicaid), access to health
services for students and their families, benefits and cost-
effectiveness of school health services
Data from Gordon SC, Barry CD: Development of a school
nursing research agenda in Florida: a Delphi study. J Sch Nurs
22(2):114–119, 2006.
Active Learning
Attend a meeting of the school nurse association in your area.

Identify the major pros and cons of being a school nurse. Look
at factors such as working conditions, number of children
assigned to each nurse, job functions, and job satisfaction.
School-Based Health Centers
School-based health centers are one of the best ways to offer
comprehensive health care services to school-age children and
adolescents. It is important to note that the center or clinic
works in collaboration with, but does not take the place of, the
school nurse. The collaboration between the school nurse and
the SBHC staff prevents fragmented care and duplication of
services. SBHCs provide an interdisciplinary team approach
with personnel such as nurse practitioners, social workers,
psychologists, and physicians. Services provided in these
centers include nutrition education, injury treatment, general
and sports physicals, prescriptions, pregnancy testing,
laboratory services, immunizations, gynecological
examinations, medication dispensing, social work services, and
management of chronic illnesses. Close collaboration must exist
within and among the community, the educational board, and
the families for such a center to develop and flourish.
Active Learning
· 1. Visit a comprehensive school-based clinic in your
area. Discuss how the care given in this type of clinic differs
from the care that a school nurse can provide. Review the
protocols of both settings and see how they differ.
· 2. What is the cultural makeup of your local area?
How should this knowledge influence the school nurses’
practice?
Future Issues Affecting the School Nurse
Our nation’s youth are our greatest asset and our hope for the
future. The school nurse’s role must constantly evolve to meet
the demands of this future hope. Issues that will face the school
nurse of tomorrow include ethical dilemmas, use of telehealth,
continued threat of school violence, threat of bioterrorism, new

and emerging infectious diseases, and increase in antibiotic-
resistant diseases. The school nurse will need to understand and
appreciate the multicultural community in which he or she will
practice.
Case Study Application of the Nursing Process
Student With Lice
The nursing process is a systematic, organized approach to
problem solving that nurses use when working with clients. It is
neither fixed nor stagnant. It is a flexible process that allows for
ongoing changes. This case study illustrates the use of the
nursing process in a school setting.
Sandra Baker is a nurse at an elementary school in a small town.
A second-grade teacher brought Carrie Broussard to the clinic
and told Sandra that Carrie had been scratching her head all day
and she was worried that Carrie might have an infection.
Assessment
Carrie was 7 years old. Her shoulder-length blond hair appeared
neat and clean. When questioned by Sandra, Carrie replied that
her head had been itching for 2 or 3 days, but she denied any
pain or trauma. Sandra noted that Carrie did not have a fever or
swollen lymph nodes, but examination of her scalp revealed
multiple excoriated areas. Carrie’s hair was examined with a
Wood’s light, and Sandra saw adult lice at the base of the hair
follicles on the back of her head, near the nape of the neck. She
also saw multiple nits. Sandra learned that Carrie had two
brothers in the school and one sister who was a toddler at home.
On Carrie’s initial visit to the clinic, Sandra assessed the
following:
· • Temperature
· • Lymph nodes
· • Scalp for any abnormal findings
Diagnosis
Individual
· • Head lice

Family and Community (School)
· • Potential for spread of infestation in both family
and school
· • Educational opportunity to prevent the spread of
lice by teachers and family members
Planning
Sandra was familiar with the school district’s policy that covers
head lice in schoolchildren. According to the policy, the nurse
must do the following:
Individual
Long-Term Goal
· • Carrie’s return to school after successful treatment
Short-Term Goals
· • Contact Carrie’s parents to tell them about the lice.
· • Inform Carrie’s parents that she must be picked up
from school.
· • Recommend treatment based on school protocol.
· • Provide guidelines for returning to school.
Family and Community
Long-Term Goal
· • Ensure that the teachers, staff, and family members
have the necessary education relative to prevention and
treatment of head lice.
Short-Term Goals
· • Examine the hair of all other children in Carrie’s
class for lice, and treat each according to the school protocol.
· • Check the hair of all siblings who attend the school
for lice.
· • Check the hair of all students in the siblings’
classes if lice are identified.
Intervention

Family
Carrie’s brothers, David and Paul, were brought to the clinic for
examination. Both brothers had lice. Sandra contacted Mrs.
Broussard, explained the situation to her, and requested that she
come to the school to pick up her children. When Mrs.
Broussard arrived at the school, Sandra gave her
written information on treatment and prevention of lice and
showed her what nits and lice look like. Mrs. Broussard was
also instructed to check other members of the family not
attending this school, especially those who share hairbrushes,
pillowcases, and towels, because all family members with lice
must be treated or the lice would continue to be passed from
member to member. Sandra also explained procedures for
cleaning combs, brushes, bedding, and potentially contaminated
clothing and toys. Finally, Mrs. Broussard was informed that
the children could return to school the day after treatment.
It was obvious to Sandra that Mrs. Broussard was embarrassed.
To ease her mind, Sandra carefully explained that head lice are
highly contagious, are easily passed from child to child, and are
not an indication of poor hygiene. Mrs. Broussard repeated the
instructions and left with her three children.
Community
Sandra examined all of the students from each of the Broussard
children’s classes for head lice. From the three classes, she
identified five more children with head lice and notified their
parents. Those children had siblings in three additional
classrooms and she repeated the procedure for each of them. At
the end of the day, she had identified a total of 15 children with
head lice and contacted all parents.
Sandra investigated whether the teachers and staff desired an
information session on the transmission and spread of head lice
because so many students had lice. She discovered that it had
been 2 years since this was done, and so she arranged a class for
the coming week for the teachers and teachers’ aides to learn
how to identify and treat head lice.

Evaluation
Individual and Family
Mrs. Broussard brought Carrie, David, and Paul to school the
following day, and on examination Sandra found their hair to be
free of lice and nits. Mrs. Broussard expressed her appreciation
for the nurse’s help and nonjudgmental approach to the
problem.
Community
Over the next 2 days, Sandra reexamined all of the children in
the affected classrooms and found that the infected children had
been successfully treated and that there were no new cases. New
cases were not identified during the remainder of the semester.
The teachers and staff gave her positive feedback about the
head lice education class and asked for it to be repeated at the
beginning of each school year.
Levels of Prevention and School Health
School nursing encompasses all three levels of prevention (i.e.,
primary, secondary, and tertiary), and all three may be practiced
individually or concurrently. Table 30.3 lists examples of
school nursing interventions for each of the three levels of
prevention.
TABLE 30.3
Examples of Prevention and the Role of the Nurse in the School
Setting
Example
Nurse’s Role
Primary Prevention
Nutrition education
Provide education to children and parent(s); consult with
dietary staff
Immunizations
Provide for or refer to source(s) for immunizations; offer
consultation for immunization in special circumstances
Safety
Provide safety education; inspect playgrounds and buildings for
safety hazards

Health education
Teach healthy lifestyle education; develop health education
curriculum for appropriate grade levels; provide health
education to parents, faculty, and staff; develop suicide
prevention and sex education programs
Secondary Prevention
Screenings
Schedule routine screenings for scoliosis, vision and hearing
problems, eating disorders, obesity, depression, anger, dental
problems, and abuse
Case finding
Identify at-risk students
Treatment
Administer medications; develop individualized health plan;
implement procedures and tasks necessary for students with
special health needs; administer first aid
Home visits
Assist with family counseling and assess special and at-risk
students
Tertiary Prevention
Referral of student for substance abuse or behavior problems
Serve as an advocate; assist with resource referrals; assist
parents, faculty, and staff; consult with neighborhood and law
enforcement officials; initiate outreach programs
Prevention of complications and adverse effects
Follow-up and referral for students with eating disorders and
obesity; participate with faculty and staff to reduce recurrence
and risk factors; serve as a case manager
Faculty and staff monitoring
Follow-up for faculty and staff experiencing chronic or serious
illness; follow-up of work-related injuries and accidents
Summary
Components of a comprehensive school health program have
been clearly identified and discussed. Many of the Healthy
People 2020 objectives specifically relate to issues that can be
addressed in the school setting. The role of the school nurse has

changed dramatically since its inception and continues to evolve
to meet the demands of school-age children, their parents, and
the communities in which they live. School nurses continue to
reduce the number of days and the frequency with which
students miss school related to illness. They have become child
advocates, counselors, health promoters and collaborators,
educators, researchers, and resources in both the school and the
community.
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Chapter 1
Strategic Planning and the Marketing Management
Process
istockphoto/Thinkstock

Learning Outcomes
By the end of this chapter, you should:
Understand the fundamentals, concepts, and func�ons of
marke�ng and marke�ng management.
Know the four elements of the marke�ng mix and be able to
provide examples of the common areas of decision
making related to each.
Recognize the purpose, goals, and basic design of a marke�ng
plan.
Understand how different levels of strategy work together to
promote the objec�ves of the firm.
3/26/2019 Print
Ch. 1 Introduction
This chapter inves�gates the fundamentals of strategic
planning and the marke�ng management process. We begin
with the basics of marke�ng: What is it and
why is it of value? You may already be familiar with
some of the core concepts of marke�ng from previous
coursework or your professional experience. Just to be
sure, we review the essen�al func�ons and precepts of
the discipline right at the start. We then move on to an
examina�on of the process of marke�ng
management and the development of strategy. This sec�on
highlights the strategy alterna�ves available to the

organiza�on and how the marke�ng mix can be
deployed to achieve strategic objec�ves. We then examine
how a marke�ng plan iden�fies the specific tac�cs for
the implementa�on of strategy. The concluding
sec�ons of Chapter 1 examine how different levels of
strategy interact to guide the organiza�on.
***
Throughout my career I have traveled extensively and
experienced my fair share of layovers and delays at
airports. I have found that reading and conversa�on are
the two most reliable ways to pass the �me while
wai�ng for flights to arrive, weather to clear, and
bo�lenecks to resolve themselves. On one such occasion
in
Toronto, I was cha�ng with a flight a�endant about our
respec�ve career choices and ambi�ons. Once I had
explained that I taught marke�ng at a university and
did some work as a marke�ng consultant as well, she
seemed disappointed. "Marke�ng? Really?" she asked
incredulously. "I mean, you sound like a very smart
man. . . . isn't that kind of a waste?" I was stunned and
a li�le embarrassed . . . and never did find a suitable
response before the conversa�on migrated to other
topics. If given a second chance, I would offer a good
defense for my choices. I would explain that there's more
to marke�ng than she probably realized. I would do
my best to explain away the bad rap that the field has
go�en over the years. I would try to impress upon her
the economic value and social benefits that we all
derive from a vast array of diverse marke�ng ac�vi�es.
But I s�ll think about that conversa�on every so o�en.
It helps me to keep things in perspec�ve.

3/26/2019 Print
1.1 The Importance and Scope of Marketing
Marke�ng has been defined in many different ways over
the years, and simply defining the term has been a
conten�ous and controversial topic in both academic
and business domains for nearly a century. It is a
business discipline that can be defined according to its
ac�vi�es, func�ons, processes, roles, values, scope,
economic u�lity, and social significance based on the
priori�es of its advocates and cri�cs. This text focuses
exclusively on the processes of effec�ve marke�ng and
marke�ng management from a business decision maker's
perspec�ve. In this regard, the prac�ce of marke�ng can
be defined as "the management process
responsible for iden�fying, an�cipa�ng, and sa�sfying
customer requirements profitably" (Chartered Ins�tute of
Marke�ng, 2011). More specifically, marke�ng
management can be understood as "a set of processes for
crea�ng, communica�ng, and delivering value to customers
and for managing customer rela�onships in
ways that benefit the organiza�on and its stakeholders"
(American Marke�ng Associa�on, 2011).
Both defini�ons stress that understanding buyers' wants
and needs is at the very heart of marke�ng's role in the
crea�on of customer value. Increasingly
compe��ve global markets and rapidly shi�ing consumer
needs have increased the complexity of markets and

amplified the importance of the marke�ng func�on.
Consequently, marke�ng and market research have emerged
as essen�al core competencies for most types of
organiza�ons. The responsive character of the
marke�ng func�on to both rapid changes and gradual
shi�s in both micro- and macro-environment condi�ons
have made effec�ve marke�ng an essen�al tool for
both nonprofit and for-profit organiza�ons. In short,
marke�ng management provides the ability to succeed by
effec�vely mee�ng the needs of target customers in
a dynamic environment.
Marke�ng is essen�al to the effec�ve promo�on and
successful opera�on of most business organiza�ons. The
scope and pervasiveness of this essen�al func�on is
evident from both the aggregate economic impact of
marke�ng and the range of jobs in the field. "Sales
employees in manufacturing, service, and other industries;
retail employees; and workers in transporta�on,
communica�ons, and other related groups represent
between one-fourth and one-third of the civilian labor
force.
About 50 cents of every retail dollar goes to cover
marke�ng costs" (World Academy Online, 2011).
Marke�ng provides a very broad range of employment
opportuni�es throughout business and industry, as
described in Table 1.1.
Table 1.1: The 26 marke�ng occupa�ons
Product Management Adver�sing Retailing Sales Marke�ng
Research Non-Profit
Product Manager,
consumer goods.
Develops new

products that can cost
millions of dollars,
with advice and
consent of
management. A job
with great
responsibility.
Account execu�ve.
Maintains contact with
clients while
coordina�ng the
crea�ve work among
ar�sts and
copywriters. In full-
service ad agencies,
account execu�ves are
considered partners
with the client in
promo�ng the product
and aiding in
marke�ng strategy.
Buyer. Selects products
a store sells; surveys
consumer trends and
evaluates the past
performance of
products and
suppliers.
Direct. Compensa�on is
based mostly on
commission.
Project manager,

supplier. Coordinates
and oversees the
conduc�ng of market
studies for a client.
Marke�ng manager.
Develops and directs
mail campaigns,
fundraising, and public
rela�ons for nonprofit
organiza�ons.
Administra�ve
manager. Oversees
the organiza�on within
a company that
transports products to
consumers and
handles customer
service.
Media buyer analyst.
Deals with media sales
representa�ves in
selec�ng adver�sing
media; analyzes the
value of media being
purchased.
Store manager.
Oversees the staff and
services at a store.
Sales to channel. Sells
to another step in the
distribu�on channel

(between the
manufacturer and the
store or customer).
Compensa�on is salary
plus bonus.
Account execu�ve,
supplier. Serves as
liaison between client
and market research
firm; similar to an
adver�sing agency
account execu�ve.
Opera�ons manager.
Supervises
warehousing and
other physical
distribu�on func�ons;
o�en directly involved
in moving goods on
the warehouse floor.
Copywriter. Works
with the art director in
conceptualizing
adver�sements; writes
the text of print or
radio ads or the
storyboards of
television ads.
Industrial/semi-
technical. Sells supplies

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