Illinois School Nurses...I need your help!!!

Rosie67 · Apr 13, 2009

Oh My!!! Not only unsanitary but quite bad for the skin. Tell her you need a doctor order to let him sit in soiled pants all day. Have Mom sign a release and speak with the MD. Sometimes I just give the MD a courtesy call and let them know my concerns. This just doesn't sound right to me. It's more embarrassing to stink in class than change clothes? I have a 6th grader who urinates at least once a month d/t inappropriate bladder stretch reflex. She wouldn't even know it, but her entire class would after the stink settles in. I keep clothes down here for her now. I don't know of a "law" but nursing judgement and the nursing process are enough for me!!! Good Luck.

cowgirlBSN · Apr 13, 2009

Thanks for your reply, mom is fighting us and threatening to bring a lawyer up here since we've been making him change clothes after we find out he's urinated. Can you believe that? I've talked to our local health dept and she recommended making up a district policy on the issue. Mom is also saying that their doctor is saying that we should not be requiring him to change clothes or use any punitive measures when he does this. What a crock. I'm waiting on the nurse to call me back from his doctor's office...We shall see...

bergren · Apr 13, 2009

For Illinois issues, contact Victoria Jackson the state school nurse consultant or her assistant Marie Irwin. You should be on her listserv.

'Is there any Illinois law saying that this child HAS to change his clothes after he has urinated in his pants?" I have never heard of such a law.

"repeatedly urinates in his pants " How many days a week? how many times a day? How much?

How do you find out he has urinated? Is he obviously wet? Getting other things wet?

What are you changing him into?

Do you have a authorization to speak to the physician? Does this doctor know what he is doing? Has he ruled out physical causes for this? Has the child been seen by a urologist? Ask mom what the cystogram showed.

" About 1% of healthy children over the age of 5 years have troublesome daytime wetting. ..... A potentially important relationship exists between day wetting, infection, reflux and upper tract damage, which is expressed in an extreme form in the syndromes of incoordinated voiding and progressive renal damage. Most children who wet by day have unstable bladders. Many of them adopt characteristic holding postures. ... Between 10% and 15% of children who wet by day become dry during the next 12 months.... place responsibility on the child and result in the child voiding more frequently and completely. Reminder alarms and other behaviour therapies have proved effective. There is no satisfactory evidence for the efficacy of drugs." http://www.springerlink.com/content/w2867n4547564214/

From the NIH:

http://kidney.niddk.nih.gov/kudiseases/pubs/uichildren/

What causes daytime incontinence?

Daytime incontinence that is not associated with urinary infection or anatomic abnormalities is less common than nighttime incontinence and tends to disappear much earlier than the nighttime versions. One possible cause of daytime incontinence is an overactive bladder. Many children with daytime incontinence have abnormal elimination habits, the most common being infrequent voiding and constipation.

An Overactive Bladder

Muscles surrounding the urethra--the tube that takes urine away from the bladder--have the job of keeping the passage closed, preventing urine from passing out of the body. If the bladder contracts strongly and without warning, the muscles surrounding the urethra may not be able to keep urine from passing. This often happens as a consequence of urinary tract infection (UTI) and is more common in girls.

Infrequent Voiding

Infrequent voiding refers to a child's voluntarily holding urine for prolonged intervals. For example, a child may not want to use the toilets at school or may not want to interrupt enjoyable activities, so he or she ignores the body's signal of a full bladder. In these cases, the bladder can overfill and leak urine. In addition, these children often develop UTIs, leading to an irritable or overactive bladder.

Other Causes

Some of the same factors that contribute to nighttime incontinence may act together with infrequent voiding to produce daytime incontinence. These factors include

small bladder capacity

structural problems

anxiety-causing events

pressure from a hard bowel movement (constipation)

drinks or foods that contain caffeine, which increases urine output and may also cause spasms of the bladder muscle, or other ingredients to which the child may have an allergic reaction, such as chocolate or artificial coloring

Sometimes overly strenuous toilet training may make the child unable to relax the sphincter and the pelvic floor to completely empty the bladder. Retaining urine, or incomplete emptying, sets the stage for UTIs.

" social embarrassment of the situation" That is a major concern and calling attention to it by forcing him to change could really set him up for harrassment and bullying.

I think it is extremely important to handle this senstively or the long term damage done to this young man will be far worse than the problem of wet pants.

Have you had mom in for a team meeting? Is he on a behavior plan? Does the teacher allow the students adequate time to use the toilet? Are the bathrooms in your building safe places? Are there doors on the stallls? Can you offer your bathroom? How was it handled last year?

I would make sure he has has a cystogram and a unirnalysis, and get the doctor to order accomodations re: frequent bathroom visits, assess and cut down on caffiene consumption, put the child on a behavior plan for frequent bathroom visits and get both he and mom to participate in a plan for when there is an acccident.

cowgirlBSN · Apr 13, 2009

yes bergren, he has a medical diagnosis and we spoke to his doctor today. He has severe constipation which is causing his urinary incontinence. We understand that, but our issue is that after he does urinate he will not tell anyone and choose to sit in it until someone notices or smells him. I would say we catch it a couple times a week. His mother has reported to us that he has came home with soiled clothes that have dried because no one noticed and he didn't let anyone know. So I would venture to say it happens almost daily and mom has said it happens at home as well. He has also admitted in front of our principal and his mother that he knows he does it but he doesnt want to do anything about it. As a school we are aggrivated because we have been dealing with this issue since he was in kindergarten and bent over backwards to accomodate him. Now because we want to require him to wear a diaper type barrier mom wants to sue us. This is a health concern for not only him but the rest of the school he comes into contact with. My district also wants me to write a policy for the future about bodily fluids. Can you direct me how to make one?

bergren · Apr 14, 2009

I can understand why you are aggravated, and you can write a policy and also put an intervention for this behavior in place.

So does he have encopresis? http://www.mayoclinic.com/health/encopresis/ds00885 Sounds like it. It includes trying to deny and hide the soiling. Did they rule out sexual abuse and Hirshsprungs? What is being done for the constipation? The chronic constipation needs to be treated and the constipation and the wetting require a behavior plan. You said he has been doing this since kindergarten. Has he had a consultantion with the school psychologist? A mental health counselor?

Here is a care plan:

http://nursingcareplan.blogspot.com/2007/05/ncp-elimination-disorders-enuresis.html

Try to figure out a face saving way for him to change. Do not expect him to come forward to comply with a policy - he will continue to hide it.

I have never been "taught" how to write a policy. What I did:

- look at the format your district uses

- write a policy

- ask the process for review and submission of a new policy. It might be right in the front of the P & P manual. If not check with the principal.

kidsnurse1969 · Apr 14, 2009

I suggest that you refer to the Illinois Department of Public Health document "Chronic Infectious Diseases in Schoolchildren". The link is: http://www.idph.state.il.us/health/infect/chronicinfectiousdiseases2003.pdf

Of particular interest will be chapter 3 regarding Procedures for school management of Infectious disease. It address Bloodborne pathogens and Universal Precautions. Since there is not any guarantees that your student (or any student) does not have an unknown infectious disease, all precautions should be made regarding any blood or body fluids. It also addresses diapering issues. Some of this information would be good for your policy.

I also wonder if OSHA could help.

SchoolNurseBSN · Apr 14, 2009

You need to find a way for this student to be comfortable to come forward. Maybe a hand signal to the teacher or a password. He may even need some sort of positive reinforcement - 5 minutes computer time, snack...whatever works for him when he does come forward. sometimes I resort to bribery....

I would continue to support this family in finding an answer.

The other nursing consideration you have to take into account is the potential for skin breakdown with him sitting soaked in urine for long periods of time,

Good luck!

cowgirlBSN · Apr 14, 2009

Thank you all for your replies. You have been very helpful. Bergren, thank you so much for your help, and the care plan. Yes he does have encopresis. From speaking to his doctor in Springfield yesterday it sounds like mom has been very noncompliant over the years in his treatment. She waited 2 years to return to this doctor for follow up. The doctor did say that these kids will never admit that they have soiled themselves since they are so used to doing so and that he should not recieve any punishment for doing so. How can you say that a child is allowed to soil themselves, and then not tell anyone that he has done so or clean himself up? As a school district our principal is requiring him to do so or become home bound. He simply cannot be allowed to urinate or deficate in the school and sit in it all day and expose the rest of the school. We've decided that if mom wants to fight us with a lawyer she can just bring it on! I really don't think she has much to go on. I think they have ruled out sexual abuse. That was something I was suspecting as well. However I think it is an excellent idea for the child to see a counselor or psychologist. I am sure mother will object that suggestion.

bergren · Apr 14, 2009

'As a school district our principal is requiring him to do so or become home bound. "

Be careful - the child qualifies for a Section 504 and Office of Civil Rights has notified many school districts if they fail to have a 504 plan and deny the child's right to accomodations / equal access to education they will come down hard. The critieria for a 504 plan was reduced significantly Jan 1 2009 and OCR has put school districts on notice. Here is the US Department of Education link: http://www.ed.gov/about/offices/list/ocr/504faq.html

SchoolNurseBSN · Apr 14, 2009

The child has a right to an educaction in the least restrictive environment possible. Home is one of the most restrictive!

In situations such as these, the school must accomodate the student whether it is convenient for the school staff or not.

Bergren is right - under 504 - mom has plenty of leg to stand on!

However, if mom seems to be non-compliant in regards to the health of the child AND abuse is expected - I would think a CPS referral would be warranted.

Purple_Scrubs, BSN, RN · Apr 15, 2009

I understand that this child and family have rights under 504 plans, but what about the rights of the rest of the student body (not to mention staff and visitors) to not be exposed to bodily fluids and potential pathogens? Wouldn't allowing this to go on also violate some laws (maybe OSHA?)

If something is not done to correct this, another kid's parent is likely to sue because of the unsafe environment for their child. I just cannot see exposing the entire school to body fluids because of one child's right to a least restrictive environment! If the child and family were compliant, this would not be an issue, but since the child cannot be trusted to take care of the problem and the parent is not complying with medical treatment, I do not see what other alternative the district has!