Limited Mobility

This resource provides current and comprehensive health care information for school health nurses. Related procedures, instructional videos and downloadable skills checklists can be searched by selecting the [More Information] button at the bottom of this web page.

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Overview

Students may have mobility issues for numerous reasons including neuromuscular diseases including Duchenne muscular dystrophy, birth defects such as spina bifida, and movement disorders such as cerebral palsy or as a result of trauma. It would be important for the school nurse to review the student’s health history and speak with the student, parents/guardian, and health care provider to learn more about the student’s mobility needs and underlying health condition.

Mobility Devices:

Students with mobility issues will most likely have a mobility aid, this could include manual or power wheelchairs, scooters and/or strollers, standing lifts and ceiling lifts. Considering the instructions for use are specific to each device, the school nurse should review the manufacturer’s website and other resources for more information.

Transferring and Lifting Devices:

In addition to wheelchairs and scooters, students may also require the use of positioning and transferring tools including Hoyer Lifts. School staff who will be using the lift, including the school nurse, should be trained on how to properly use the lift. In addition to the Hoyer Lift there are several other patient lift devices. The school nurse should discuss with their school’s physical therapist, if applicable, regarding who is responsible for educating, training, and supervising unlicensed assistive personnel (UAP) in the use of patient lifts and should refer to the lift manufacturer’s manual and other resources for training materials.

The U.S. Food and Drug Association has developed information on patient lifts and a Patient Lifts Safety Guide.

Skin Assessment:

In addition to ensuring that the student has the proper equipment and trained school staff to support their mobility needs in the school setting, the school nurse will also want to develop a plan of care to monitor and respond to any skin care needs since the student may be at risk for pressure sores due to limited mobility. This may be done in collaboration with the physical therapist, if applicable.

The first step in the development of a skin care plan would be to assess the student’s skin, looking for any signs of skin breakdown, infection, or irritation. The school nurse should pay close attention to areas that are common pressure sore sites. Common pressure sore sites for a student who is wheelchair bound include the:

• Scapula
• Sacrum
• Ischium
• Posterior knee
• Sole of the foot

(Potter et al, 2023).

When completing the assessment the school nurse should observe for skin redness that does not go away within 30 minutes after pressure is relieved, change in skin color or temperature (warmer or cooler than other skin areas nearby), and/or skin irritation such as a scraped area, break in the skin, blisters or sores (Children’s Minnesota, 2015). A helpful resource to assess the student’s risk factors for skin breakdown is the Braden QD Scale (Baker, Mondozzi, & Hockenberry, 2024).

If the school nurse will be delegating transfers or repositioning of the student to a UAP, then the school nurse should develop a protocol that outlines what actions the UAP should take if they were to notice any skin abnormalities such as rash, redness, swelling, or skin breakdown, or drainage since only the school nurse can perform an assessment. If the school nurse is delegating transfers and repositioning, the school nurse should discuss with the student, parent, and health care team to determine how often a thorough skin assessment should be performed by the school nurse.

Prevention of Pressure Sores:

Another important aspect of the skin care plan would be interventions to reduce the risk of developing pressure sores. The school nurse should collaborate with the student, parents/guardian, health care provider, occupational therapist, and physical therapist to develop interventions that will help to promote circulation and decrease pressure on common pressure sore sites such as frequent position changes, range of motion exercises, and/or pressure-relief cushions.

Delegation

There are a number of factors for the school nurse to consider when deciding whether to delegate transfers of a student with limited mobility to unlicensed assistive personnel (UAP). This section will provide a list of questions that the school nurse should answer to assist them in determining whether it is appropriate and safe to delegate the procedure. It is also important to remember that the questions related to delegation need to be answered for every individual student. The decision to delegate is based on circumstances related to the student, the nurse, the UAP, and the situation.

If a school employed physical therapist is involved in the care of the student who has limited mobility, the school nurse will want to discuss with the physical therapist and the school administration which staff members are responsible for the student’s care and what specific duties they will be trained on. For instance, who is responsible for the education, training, and supervision of UAPs performing transfers of the student, as this may be supervised by the physical therapist rather than the school nurse. 

Questions to Ask to Inform Safe Delegation: The delegation questions below are based on the American Nurses Association’s Decision Tree for Delegation by Registered Nurses (ANA, 2012).

1. Has a school nurse performed an initial student assessment to determine needs?
   • The school nurse should not delegate the procedure to a UAP until they have completed the initial assessment.
2. Does school district policy, the school nurse’s job description, and the UAP’s job description allow transfers of wheelchair bound students to be delegated?
   • Although the Missouri Nurse Practice Act allows for registered nurses to delegate transfers of wheelchair bound students, the district may have policies that prohibit or limit the school nurse’s ability to delegate. Additionally, the school nurse’s and UAP’s job descriptions may restrict delegation as well.
3. Is the school nurse competent to perform this procedure or does the school nurse need to acquire some knowledge or skills to be competent in this procedure?
   • If the school nurse is not competent or does not feel comfortable performing this procedure they should not delegate this procedure to a UAP. The school nurse must first acquire the necessary knowledge and skill to perform this procedure competently before they can delegate it to someone else.
4. Is the student’s condition stable? Is this a new procedure for the student?  How predictable are the outcomes of the procedure?
   • A school nurse should not delegate transfers of a wheelchair bound student to a UAP if the student recently become wheelchair bound. The outcomes are not predictable; thus, a school nurse should perform the procedures until the student’s condition is stabile.
5. Does the procedure require initial or ongoing assessment during the procedure?
   • An initial or ongoing assessment is required for the procedure to be performed, the procedure should not be delegated.
6. Does the UAP have the appropriate knowledge, skills, abilities, and willingness to perform the procedure?
   • All these factors need to be considered. Although a UAP may be competent to perform the procedure they may not be willing to do so and in that situation another UAP should be identified and trained. The registered nurse must retain responsibility for the procedure until training is complete. Considering that transferring a wheelchair bound student requires strength and coordination, the school nurse should determine that the UAP has the physical ability to perform the procedure.
7. Is there a procedure and/or protocol in place for this procedure?
   • A delegated nursing procedure must have an established sequence of steps that the UAP can follow. These steps should have a predictable outcome. The steps should be outlined in a written procedure or protocol. If the written procedure/protocol has not been developed, the school nurse should retain responsibility for the procedure until the procedure/protocol is in place. 
8. Is the school nurse able to provide supervision to the UAP (direct or indirect depending on the situation)?
   • If the school nurse is not able to provide supervision, then the procedure should not be delegated. The school nurse will need to assess the situation to determine if direct or indirect supervision is required. The school nurse may also need to reassess the situation if the environment changes, for example, if the procedure is going to be performed during a time that the school nurse is not contracted to provide nursing services (i.e., over the weekend, during the summer, or if the nurse is part-time).
9. Is the student ready to assume some responsibility for the procedure?
   • The school nurse should resume responsibility for the procedure since the school nurse is the only one who can initiate teaching. The school nurse would also want to observe the student performing the procedure to ensure that the student is competent. Once the school nurse has determined that the student is competent and can safely perform the procedure independently, they can delegate the supervision of the student to a UAP. If at a future date the school nurse is needed to teach the student additional skills, the school nurse would again need to resume responsibility for the procedure until the time in which the school nurse determined the student to be competent.

The Decision to Delegate:

There may be times when the school nurse and school administrator have conflicting opinions on the delegation of a procedure to a UAP. The school nurse may feel that delegation is not appropriate, or the administrator may want the school nurse to delegate a procedure to an UAP that the school nurse feels is not competent. In these situations the school nurse may need to educate the administrator that the school nurse has a professional and legal responsibility to determine if delegation of a nursing procedure is appropriate and safe (ANA, 2012). See Fact Sheet for School Administrators, Families, and School Personnel: Nursing Delegation Requires the School Nurse and Navigating Delegation in the School Setting (pdf) to assist school nurses communication with the school administration.

School Environment

The student with mobility issues will most likely have significant needs related to the school environment and the school nurse will want to ensure that all the stakeholders are working collaboratively to address the student’s needs. Although the school nurse may not be the main individual responsible for ensuring the student’s needs are being met, they may want to verify that the following areas are being addressed:

• Are all school areas accessible to the student? (i.e., library, band room, auditorium)
• Lunchroom accessibility
  • Does the table height need to be adjusted for the student?
  • Will the student need assistance with eating?
  • Can the student go through the lunch line independently?
  • Can the student carry a lunch tray?
  • Will the student need adaptive feeding equipment?
  • Will the student need to eat in an area other than the cafeteria?
• Classroom accessibility
  • Is there space for turning a wheelchair around completely?
  • Is the carpeting low-pile and secured tightly around the edges to allow a wheelchair or walker to maneuver safely?
  • Are tables and desks at least 27 inches high and 30 inches deep?
  • Are all controls (electrical, mechanical) such as sinks in the science lab accessible?
• Hallway accessibility
  • Are the drinking fountains and their controls accessible?
  • Are the floors and stair treads covered with non-slip material?
  • Can the student open their locker?
  • Does the student require an alternate lock?
  • Would the student benefit from having a locker at the beginning or end of a row of lockers to allow more room to maneuver?
  • Does the student need locker shelves & hooks lowered to an appropriate level?
  • Can the student independently open entrance, exit, and classroom doors?
  • Can door tension be adjusted or will power-assisted doors be needed?
• Elevator accessibility
  • Are call buttons at a level the student can reach?
  • Can the student use the elevator or lift without assistance?
  • Is there an emergency system in place in case the elevator malfunctions?
  • Has a plan been developed regarding the evacuation of the student if the elevators are non-functional or when the use of the elevator is not permissible (i.e., fire)?
• Evacuation (See the Emergency Preparedness section for more information)
  • Will the student require help evacuating the building during an emergency?
  • How many staff members will be needed to assist the student with evacuation?
  • Does the student require a specific evacuation route (due to obstacles (stairs, limited space for maneuvering wheelchair, etc.)?
  • Does the evacuation plan address different times of the day and schedule changes (including every classroom/area of the school the student may be in)?
  • Has a plan been developed to address how to remove the student from the school if they are not on ground level and elevators or lifts cannot be used?
  • Has the school consulted with the local Emergency Medical Services on the evacuation plan?
• Lockdown situations (See the Emergency Preparedness section for more information)
  • Will the student be able to access the classroom lockdown location?
  • Will the student need assistance in accessing the “lockdown area” of the classroom?
  • Has the school consulted local Emergency Medical Services on the lockdown plan?
• Physical education class
  • Can the student access the gym, locker room, and weight room?
  • Is there enough space in the locker room for the student to maneuver?
  • Can the student participate in the general physical education class?
  • Will the student need help to participate in the general physical education class?
  • Does the student require adaptive physical education?
  • Will the student need modified physical education equipment?
  • Is the student able to use the standard lock on the locker?
  • Is the student able to change into PE clothes, if needed, without assistance?
  • Is the swimming pool accessible, if applicable?
  • Does the student need a lift, adult assistance, and/or special flotation equipment?
• Recess
  • Is there an accessible route of travel to the playground?
  • Does the student require assistance to get to the playground?
  • Are there accessible ground level play activities?
  • Is the student able to maneuver on the playground safely?
  • Will the student need additional playground supervision?
• Restroom access
  • Will the student need assistance?
  • Will the student be able to use the general restroom or a private restroom?
  • Does the student need adaptive equipment (i.e., grab bar, raised seat)
  • Will the student need space to store equipment in the restroom (i.e., diapers, catheterization supplies)?
  • Can the student reach the sink, soap, and towel dispenser?
• Parking
  • Is there a parking space/drop off area close to the entrance?
  • Is there a path to the entrance that does not require stairs?
  • Are curb cuts needed?
  • If a ramp is needed, is it made out of non-slip material?
  • Are slopes of the ramp no greater than 1:12?
• Transportation
  • Does the student require accommodations related to transportation?
    Does the bus driver require mobility or student health education/training?
    (Clarke, Embury, Yssel, 2014; Wisconsin Department of Public Instruction, 2005).

The Wisconsin Department of Instruction has developed the Addressing the School Safety and Mobility Needs of Students with IEPs checklist. See The American Academy of Pediatrics policy statement, School Bus Transportation of Children With Special Health Care Needs.

Students

Health History Questions: The school nurse may want to ask the student and their parents/guardians the following questions:

• Current health conditions
• Medications
• Allergies
• Previous hospitalizations and surgeries
• Most recent hospitalization (if applicable)
• Type(s) of mobility aids used
  • Including the name of the device
• Manufacturer of mobility aids
• Insurance coverage
• Health care provider(s) name and contact information
• Home health agency
• Preferred hospital, if applicable

Assessment Questions: The school nurse may want to consider asking the student and their parents/guardians the following questions:

1. Does the student have any physical limitations, injury, or paralysis that limits their ability to move on their own?
2. Can the student change their position by themselves easily?
3. Tell me about any pain the student has when they walk, sit down, or move about school.
4. Can the student feel pressure when sitting or lying down?
5. Is the student’s skin sensitive to heat or cold?
6. Does the student have any problems or accidents leaking urine or stool?
7. What help, if any, does the student need when using the toilet?
8. Does the class environment support the student’s needs (i.e., desk/seating options)?
9. What are the student’s and the parent’s goals associated with the student’s mobility?
10. Does the student and/or their parents/guardian have any student mobility concerns?
11. What challenges does the student face in dealing with their health condition?
12. Do you school staff sufficient support the student’s mobility management issues?
13. Who has the student been going to when they need help?
14. How often does the student have bad feelings about coming to school because they are worried/afraid/embarrassed about something (peers, assignments, teacher)?
15. Has the student had to change any social activities because of their mobility issues?
16. Does the student attend before or after school care?
17. Does the student participate in school-sponsored clubs or athletics?
18. Would the student benefit from evaluations or assessments in any of these areas: physical therapy, occupational therapy, speech/language therapy, assistive technology, adapted physical education, functional behavior, psychology, hearing and vision?
19. Would the student benefit from additional academic support and/or modified education (i.e., copies of notes, extra time, reduced workload, simplified instructions, alternative formats for presentation of material, 504/IEP)?
20. Does the student have an Individualized Health Care Plan (IHCP)?
21. Do you need a plan for this student’s individual needs in the event of a building crisis?
22. If shelter-in-place were required or the school day needed to be unexpectedly extended, what additional supplies, equipment, and health care provider orders would be needed?
23. How is the student transported to and from school?

(Clarke, Embury, & Yssel, 2014; Llorens, McKee, & Dempsey, 2020; Potter et al., 2023; p. 1332)

Communication

It is important for the school nurse to discuss with the student and their family the best way(s) to communicate with them. Does the parents/guardian have a preference (i.e., email, text, telephone call)? Do the parents prefer to have the communications sent to both parents or is there a parent who manages the communication with the school nurse?

The school nurse may want to consider having the parents/guardians complete a Health Insurance Portability and Accountability Act (HIPAA) compliant medical release form to facilitate communication with the student’s health care team. Although HIPAA does not require parental consent to allow the school nurse to discuss the student’s treatment plan, such as medications and nursing procedures, with the student’s health care provider, having a signed consent form would undoubtedly make the process go smoother for all involved parties (U.S. Department of Health and Human Services & U.S. Department of Education, 2008).

FERPA HIPAA Consent Sample (NASN)

In addition to the student’s health care provider, a student with limited mobility will most likely have other health care professionals on their team, including other school-based health care providers, such as physical or occupational therapy. The school nurse will want to collaborate and communicate with the entire team to help facilitate appropriate care coordination.

Medication

Students with limited mobility may take medications related to their underlying health condition. The school nurse should assess the student’s prescription and over-the-counter medications. If medications are to be administered at school, the school nurse will want to obtain the necessary health care provider order(s) and parent/guardian authorization. See Documentation section. The Parent Project Muscular Dystrophy has developed a resource that discusses Safe and Unsafe Medications for people with muscular dystrophy.

Field Trips

Field trips and other out-of-school activities will require significant planning by a team of school staff, including the school nurse. Students with mobility issues cannot be excluded from field trips. The needs of students with mobility issues related to field trips will be dependent on the student, their health concerns, and the details of the field trip. There are numerous considerations that will need to be evaluated when planning a field trip with a student who has mobility issues. This list is not exhaustive. Note, this list only considers factors related to the student’s mobility limitations. If the student has other health conditions, additional factors will most likely need to be considered.

It is important to note that the Section 504 of the Rehabilitation Act does not allow for a student with a disability to be excluded from a field trip due to their disability.

1. Does the student require someone to accompany them on the trip to assist with their mobility?
2. If the student does require someone to assist with their mobility, who will accompany the student on the field trip to perform necessary procedures?
   • The individual who will be assisting with the student’s mobility must have the knowledge, ability, skills, and willingness to assist with the student’s mobility (including how to use the student’s wheelchair (if applicable) and other assistive devices.)
3. Does the student have equipment or supplies that will need to accompany them on the field trip? If yes, where will the equipment/supplies be stored?
   • It is important to have all needed supplies readily available. Supplies should not be left on the bus but should be with the student at all times.
4. Are the locations that will be visited on the field trip wheelchair or ambulatory assistive device (i.e., walker, scooter) accessible?
   • Consider all outdoor and indoor locations that will be visited or stopped at during the field trip (i.e., is the trail at the park wheelchair accessible, how steep is the pathway to the building that the students will be entering, does the restaurant have a wheelchair accessible entrance, does the museum have a wheelchair accessible bathroom?)
5. Will special transportation be required to allow the student with limited mobility to attend the field trip?
6. What is the plan if emergency evacuation is necessary during the field trip?
7. Is there additional equipment that should be brought on the field trip in case the student’s mobility aid malfunctions (i.e., power or electric wheelchair)?
8. Will the student be traveling on a plane for the field trip?
   • The school may want to connect with the student’s parents/guardians regarding informing the Transportation Security Administration about the student’s health needs.

(Erwin, Clark, & Mercer, 2014; NASN, 2019; Wisconsin Department of Public Instruction, 2019)

Documentation

Health Care Provider Order: If there are medications or procedures related to the student’s limited mobility a health care provider’s order would be required. The order should contain:

• Name of the student
• Date of birth
• Name of medication or procedure
• Dose
• Route
• Time of administration/procedure
• Reason for medication administration or procedure
• If the health care provider order is for a nursing procedure, the order may also contain instructions related to when to call the health care provider.

Emergency Action Plan: Depending on the student’s underlying health condition(s) they may require possible emergency planning at school. The Emergency Action Plan should include:

• Definition of medical emergency for this student.
• Signs of an emergent or worsening condition and steps to remediate &/or seek EMS care.
• Specific actions to be taken in the emergency, based on the signs and symptoms present.
• List of individuals to be notified when this emergency occurs.
• Transportation procedures (Missouri Department of Elementary and Secondary Education & Missouri Department of Health and Senior Services, 2014, pp.72, 85).

The Emergency Action Plan should also take into consideration how the student’s limited mobility may impact the health emergency and the actions to take in response to the emergency. For example, moving a student who is wheelchair bound out of their wheelchair during a seizure or when choking could require more than one school staff person. The emergency action plan should address the specific needs required for each student. The Missouri Department of Health and Senior Services has an Emergency Action Plan template.

Parent/Guardian Authorization: In addition to the health care provider’s order, the school nurse will also need written authorization from the parents/guardians to perform any procedures that are necessary due to the student’s limited mobility or underlying health condition(s). The authorization form can be a separate document that just the parents sign or a document can be developed that combines the health care provider’s order and parent authorization in one form.

Procedures and Medication Administration: If the student has any procedures or medications that are scheduled to be administered at school, the procedures and/or medication administration will need to be documented, whether they are performed by the school nurse, a UAP, or the student. Many times the medication administration and procedures are documented in the student’s health record. The school nurse will also want to ensure that medications being administered or procedures being performed during field trips, before or after school, and/or during any school-sponsored activities are being documented.

Staff Competency Validation: If the procedures or medication administration is delegated to a UAP the school nurse should document that the UAPs knowledge, abilities, and skills have been assessed. Many times these factors are documented on a skills competency checklist (see Skill Competency Checklists). There should be a place on the skills competency checklist for the school nurse and UAP to sign to indicate that they feel competent and are willing to perform the procedure. Once the procedure has been delegated the school nurse is responsible for periodic evaluation of the UAP and their competency. The school nurse must determine how often the supervision is needed. After the school nurse has re-evaluated the UAP’s competency, they should document the date of the evaluation (Selekman & Ness, 2019; Shannon & Kubelka, 2013).  The school nurse should organize the competency documentation in a way that easily allows them to determine when subsequent evaluation and documentation of competency is needed. For more information on delegation see the Delegation section.

Individualized Health Care Plan (IHCP): IHCPs should outline the plan of care for the student, including but not limited to:

• Actions the school nurse will take to support the student’s educational attainment.
• The education and training that will be provided to school personnel.
• The development of Emergency Action Plans, including steps to be taken in case of an evacuation.
• The accompanying expected outcomes for each nursing intervention (NASN, 2020).
• Prior to completing the IHCP, the school nurse should complete a health history and physical assessment of the student. For more information on health history see the Students section.

The Connecticut Technical Education and Career System has developed a IHCP template for orthopedic impairment (Link downloads the document directly to your computer).

Section 504 Plan: Students with limited mobility may qualify for a Section 504 Plan since their health condition may impact a major life activity (walking). If the student has been identified as qualifying for a 504 Plan, the school nurse may be involved in identifying appropriate accommodations and writing the plan. Once developed, the school nurse will want to frequently review, update, and document in the 504 Plan (NASN, 2020).

Individualized Education Program (IEP): If a student with limited mobility has an IEP where “related services” include nursing services, the school nurse will want to ensure they are providing and documenting the related services in the student’s education record, whether this is paper or electronic. This documentation is necessary for the school to validate that they are providing the services that the student has been determined to be eligible for under the Individuals with Disabilities Education Act (IDEA) (Galemore & Sheetz, 2015). For more information on Section 504 Plans and IEPs see Legal Issues section.

Procedures

Go to ShowMeSchoolHealth.org > Just in Time Learning > Search “Transfer”

Emergency Preparedness

Shelter-in-Place and Other Emergency Events:

In addition to an Emergency Care Plan (see Documentation section), the school nurse must also plan for other potential emergencies such as lockdown, extreme weather events, evacuations, and shelter-in-place events. Considerable planning is needed when preparing for how to safely care for students with limited mobility during an emergency. The planning will need to be student specific and should involve a team including, but not limited to, the student, parents/guardian, school administration, teachers and aides, physical therapist, occupational therapist, school counselor, school nurse, and local Emergency Management Services (EMS) including police and fire personnel, and school transportation staff.

EMS staff should be made aware of the students in the school who may need assistance in the event that an evacuation is needed. Some schools use a “safe room”, a room where students who require assistance are transported to until EMS is able to assist with their removal (Parent Project Muscular Dystrophy, n.d.a.).

When developing an Emergency Evacuation Plan the school should consider the following:

• Who will be responsible staff for escorting the student out of the building and/or down stairs (as well as back-up members in the event a designated staff member is not there or available)?
• Will the staff person/people responsible for escorting the student change based on the time of day or class that the student is in?
• What exits will the student use (the plan should indicate if the exit location changes based on classroom location).
• Will any special supplies be needed during the evacuation, including but not limited to:
  • a transfer sling (e.g., Tuk-N-Kari),
  • an extra manual wheelchair stored on the first-floor office area,
  • packable Mylar ‘space blanket’,
  • assistive technology device,
  • whistle,
  • flashlight,
  • gloves in the event of wheels coming into contact with glass or debris,
  • walkie-talkie or cellphone?
• How much assistance will the student require during the evacuation?
  • Student follows evacuation plan procedure with minimal assistance/cues
  • Student only requires guidance/support by an adult (use of transfer belt for extra support)
  • Student will need to be carried: two-person, fireman’s carry, cradle lift, etc. (determined by individualized student need)
  • Student will require the use of a:
    • Transfer sling (e.g., Tuk-N-Kari)
    • Evac Chair
    • Stair Trac
  • Student will need to be transported to a “Rescue room”/ “Safe room”/”Area of refuge” until EMS can come and assist with evacuation.
    • “These areas are where a person can wait for assistance and call for help if they are unable to leave the building” (National Fire Protection Association, 2022. p.10)
• If a transfer sling or Evac Chair will be used, the plan should address:
  • Where the student will sit after being removed from the sling or chair.
    • May want to have an extra lightweight manual wheelchair stored on the first floor to transfer students from a sling or evac chair.
  • How many staff people will be needed to transfer the student using the sling or chair.
• Copies of building map, written instructions and evacuation plan should be kept with emergency evacuation supplies.
• Evacuation training should be provided to staff prior to start of each school year, and periodic reviews/practice sessions throughout the year
• Distribution of evacuation plans may include: Administration, health services, fire department, IEP case manager/team members (including parent/guardian and student), classroom staff, substitute teacher folders.
• As an important member of the school team, parents/guardians and the student should participate in reviewing the plan and providing input. Reviewing the plan with the student is critical, allowing the staff to reassure and familiarize them with the plan and procedure.

(Center for Inclusive Child Care, 2020; Minnesota Low Incidence Projects, 2018, p. 68-69; Region 10 Low Incidence Projects, n.d., p. 15).

If the student will be moved in his/her wheelchair, keep the following considerations in mind:

• Turn off the wheelchair’s power before lifting.
• Turn the wheelchair so it is lowered down the stairs backwards (person facing up the stairs), so the occupant cannot slip forward out of the chair and down the stairs.
• Powered wheelchairs have very heavy batteries; an evacuation chair for stairs may be needed with the powered chair to be retrieved later.
• If a seatbelt is available, use it. If the person needs to be removed from his/her wheelchair for an evacuation, ask the following:
  • How he/she prefers to be moved from the chair.
  • Whether pain or harm will result from moving extremities.
  • If any equipment is needed for immediate safety of life support (e.g. backup generator for respirator).

(Region 10 Low Incidence Projects, n.d., p.19)

The Minnesota Low Incidence Projects has created an Emergency Evacuation Plan Template.

For more information on emergency planning see Missouri School Boards’ Association’s Emergency Planning Guide for Students and Staff with Special and Functional Needs within Schools.

Legal Issues

Section 504 Plan:

Students with limited mobility may qualify for a Section 504 Plan. Section 504 of the Rehabilitation Act of 1973 as amended through the Americans with Disabilities Amendment Act (ADAA) in 2008 ensures that students who have disabilities have access to a free and appropriate public education (FAPE) (U.S. Department of Education, 2023).  FAPE provides a student with a physical or mental impairment that impacts one or more major life activities (including walking) with related services and accommodations in the general education classroom (U.S. Department of Education, 2023; NASN, 2023).  If the student does not have a 504 Plan the school nurse should determine if an evaluation is indicated (see Student section for questions to ask student and family to determine if 504 or IEP evaluation is indicated). If it is determined that the student qualifies for a Section 504 Plan, the school nurse may want to consider the appropriateness of the following accommodations:

• Supportive seating
• Raised desktop or wheelchair tray
• Assistive devices for note taking, test taking and writing
• Extra time between classes or assign a friend/buddy to help carry heavy books and supplies
• Extra set of materials to minimize transport

(Parent Project Muscular Dystrophy, n.d.a, p. 12; Parent Project Muscular Dystrophy, n.d.b, p. 13)

Individualized Education Program (IEP):

A student with limited mobility may qualify for an IEP if it is determined that they have an orthopedic impairment or if their health condition results in an intellectual disability or significant developmental delay (U.S. Department of Education, 2018). An IEP is developed by a multidisciplinary special education team. The IEP outlines the plans for special education services for the student who has a qualifying disability that interferes with learning. The IEP plan identifies what services and accommodations are needed to support the student’s education needs (NASN, 2020). Many interventions provided as part of the IEP plan are “related services”, which include school nursing services and school health services (U.S. Department of Education, 2017).

Resources

Muscular Dystrophy:

• https://www.mda.org/sites/default/files/Teachers_Guide_PT_flyer.pdf
• https://www.parentprojectmd.org/
• https://www.mda.org/sites/default/files/publications/Emergencies_Checklist_P-527.pdf
• https://www.parentprojectmd.org/care/care-and-support-materials/order-support-materials/

Emergency Preparedness:

• https://training.fema.gov/programs/emischool/el361toolkit/assets/bestpractices_evacuating_special_needs.pdf
• https://training.fema.gov/programs/emischool/el361toolkit/assets/evacuatingspecialneedspopulation.pdf
• https://crcog.org/wp-content/uploads/2017/12/Supporting-Students-with-Disabilities-During-School-Crisis.pdf

Spina Bifida:

• https://www.spinabifidaassociation.org/resource/?audience=&topic=education&post_tag=

IHCP:

• https://www.cttech.org/wp-content/uploads/2021/02/CTECS-Individualized-Care-Plan_Orthopedic.docx

References

American Nurses Association. (2012). Principles of delegation.

Baker, R. U., Mondozzi, M., & Hockenberry, M.J. (2024). The child with integumentary dysfunction. In Hockenberry, Duffy, & Gibbs (Eds). Wong’s nursing care of infants and children (12th Ed., pp. 1210-1261).

Center for Inclusive Child Care. (2020). Tip sheets. Emergency planning for children with disabilities.

Children’s Minnesota. (2015, September). Skin care for a child with limited mobility.

Clarke, L.S., Embury, D.C., Yssel, N. (2014). Supporting students with disabilities during school crisis. A teacher’s guide. Teaching Exceptional Children, 46(6), 169-78. doi/10.1177/0040059914534616

Erwin, K., Clark, S., & Mercer, S.E. (2014). Providing health services for children with special health care needs on out-of-state field trips. NASN School Nurse, 29(2), 84-8. doi: 10.1177/1942602X13517005

Galemore & Sheetz. (2015). IEP, IHP, and section 504 primer for new school nurses. NASN School Nurse, (Print), 30(2), 85–88. https://doi.org/10.1177/1942602X14565462

Llorens, A., McKee, S., & Dempsey, A.G.). (2020). In A.G. Dempsey (Ed.). Pediatric health conditions in schools. (pp. 26-27). New York, NY: Oxford Press.

Minnesota Low Incidence Projects. (2018). Meeting the needs of students with physical impairments. 

Missouri Department of Elementary and Secondary Education & Missouri Department of Health and Senior Services. Manual for school health programs. Available at: https://health.mo.gov/living/families/schoolhealth/pdf/ManualForSchoolHealth.pdf

National Association of School Nurses. (2019). School-sponsored trips -The role of the school nurse (Position Statement). Silver Spring, MD: Author.

National Association of School Nurses. (2020). Understanding student health and education plans.

National Association of School Nurses. (2023). IDEIA and Section 504 Teams – The school nurse as an essential team member (Position Statement).

National Fire Protection Agency. (2022, November). Emergency evacuation planning guide for people with disabilities.

Parent Project Muscular Dystrophy. (n.d.a). Education matters for parents and teachers. Diagnosis and early childhood. 

Parent Project Muscular Dystrophy. (n.d.b). Education matters for parents and teachers. Late childhood and early adolescence. 

Potter, P. A., Griffin Perry, A. G., Stockert, P. A., & Hall, A. (2023). Chapter 48 Skin integrity and wound care. In Fundamentals of Nursing. (11th ed.). (pp. 1276-1317). St. Louis, MO: Elsevier.

Region 10 Low Incidence Projects. (n.d.). Emergency planning for students with special needs. 

Selekman, J. & Ness, M. (2019). Students with chronic conditions. In J. Selekman, R.A. Shannon, C.F. Yonkaitis, (Eds.). School nursing, a comprehensive text (3rd ed., p 493). Philadelphia PA.: F. A. Davis Co.

Shannon, R. A., & Kubelka, S. (2013). Reducing the risks of delegation: use of procedure skills checklists for unlicensed assistive personnel in schools, Part 2. NASN School Nurse (Print), 28(5), 222–226. 

U.S. Department of Education. (2017, May 2). Sec. 300.34 related services.

U.S. Department of Education. (2018, May 25). Sec. 300.8 Child with a disability. 

U.S. Department of Education. (2023). Frequently asked questions about Section 504 and the education of children with disabilities.

U.S. Department of Health and Human Services & U.S. Department of Education. (2008). Joint guidance on the application of the Family Educational Rights and Privacy Act (FERPA) the Health Insurance Portability and Accountability Act of 1996 (HIPAA) to student health records. 

Wisconsin Department of Instruction. (2005). Addressing the school safety and mobility needs of students with IEPs.

Wisconsin Department of Public Instruction. (2019). Meeting student health needs while on field trips. Tool kit for Wisconsin schools. 

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Last updated 4/18/2025

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