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

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I have a student in 5th grade who repetedly urinates in his pants and then remains in it for the rest of the day. He will not tell anyone he has urinated and he will not go change his clothes on his own. Administration and I have worked with him and his mom for a couple years now trying different accomodations. Is there any Illinois law saying that this child HAS to change his clothes after he has urinated in his pants? Mom is telling us that his doctor says he should not be made to change clothes because of the social imbarrasment of the situation. I can't help but think it is law that this child cannot go around in soiled clothing risking the other children to come into contact with it??? Pleas help!!:bugeyes:

Specializes in School, Hospice, Triage.

Wow! I think some of this is off track now. The school is not refusing to educate the child d/t disability. The child/Mom is refusing adequate interventions to the disabiltiy, ie: change of clothing. This is a reasonable intervention that could be included in the 504, if he indeed qualifies and has one. Upon refusal on the student/Mom's part then the school must follow through otherwise. A student cannot sit in his own urine all day soaking his pants and exposing other children. Too much hang up on his "RIGHTS", and feelings. My goodness, he is urinating and sitting in it. You think no other person notices that!! It would cause more harm to have him change?? I don't think so. Having a disability and a 504 doesn't allow for that. Sit down with your Student Assistance Team and get a care plan or behavioral plan in place and make them follow it. Get the Social Worker involved. His rights are not violated.

but since we have made so many accomodations already does that count? We offer him unlimited bathroom use without question, a change of clothes, no punishment for the incontenence, or having to clean up the incident himself (janitors will clean up after him). Mom is refusing to have him wear an adult diaper and thinks he should not have to change clothes as well. I would think that would give us the right to require things such as a diaper or home bound assistance until he can control his bowel. That is to protect other students.

Schoolnursebsn, mom has been completely non compliant. She took the child the the dr 2 years ago for this issue and hasn't followed up until now, now that the issue is sooo much worse. Even though he was still having incontenence those 2 years. The thing is, the school has been very accomodating. We've offered him unlimited bathroom use and unlimited time to take care of buisness while in the bathroom. We've also said he can go change clothes when he has had an accident no questions asked and he NEVER has to clean where he has had an accident (janitors always clean the messes up). Since he and mom are being non compliant with those accomodations we are stepping it up to ask him to wear a diaper. This allows him to remain in class and continue with his peers without harming himself (skin breakdown from sitting in urine or feces all day) or his peers coming in contact with the urine or feces. That is completely reasonable I think. Mom is also refusing that situation. Where would you go from there??

Purple scrubs, I think that is one of the school's main issues with this situation as well. The rights and safety of the other students. If another student's parents were to find out and make an issue out of it where would we go from there?? This is a very delicate situation that I have NEVER had to deal with until now and I am soaking up everyone's suggestions and comments to bring back to my principal. I thank you so much for your help!

....IMHO ....

If he did not have encopresis and this was a simple behavior issue, this situation would be different. But since you have a diagnosis, a serious one, unless you have had the district psychologist or mental health person design a toileting /behavior program with the cooperation of all, MD, mom, child, etc, and which would include the consequences for wetting, you are risking a 504 violation. The behavior plan / changing situation should be part of the 504 plan.

Otherwise it is like punishing a child for coughing up blood and trying to hide it rather than treat the TB.

Everybody has a problem here, mom, child, school, teacher, nurse. All should be part of the solution. We problem - we solution.

You say this has been going on since kindergarten. This is a long, long term behavior - half his life. It is going to be much harder to extinguish now, but no reason not to get started.

Specializes in School, Hospice, Triage.

This is of such interest to me. Firstly, does he have a 504 with a behavior plan? Having a medical diagnosis does NOT automatically qualify a student for a 504. Has your team discussed him? If he indeed has a 504, and Mom and student are not following the interventions but the school is, then the school can take other measures. If he does not have a 504 or doesn't qualify for one, then you need to get your team together with Mom and possibly student to discuss a behavior plan and discuss qualification for a 504. Please let us know what you work out.

Specializes in school nursing.
Schoolnursebsn, mom has been completely non compliant. She took the child the the dr 2 years ago for this issue and hasn't followed up until now, now that the issue is sooo much worse. Even though he was still having incontenence those 2 years. The thing is, the school has been very accomodating. We've offered him unlimited bathroom use and unlimited time to take care of buisness while in the bathroom. We've also said he can go change clothes when he has had an accident no questions asked and he NEVER has to clean where he has had an accident (janitors always clean the messes up). Since he and mom are being non compliant with those accomodations we are stepping it up to ask him to wear a diaper. This allows him to remain in class and continue with his peers without harming himself (skin breakdown from sitting in urine or feces all day) or his peers coming in contact with the urine or feces. That is completely reasonable I think. Mom is also refusing that situation. Where would you go from there??

Cowgirl BSN -

I am on your side completely! I am the Stuident Support Team / 504 coordinator at my school and I know a lot about this topic. I have not had a problem even close to this. However, I am at a school with lack of parental involvement and a lot of non-compliance (ADHD kids who are constantly out of meds despite a free clinic in the school parking lot and are a constant class disruption) so I do understsand your dilemma. I also agree that there comes a time when you have to take into account the safety and welfare of the entire class / school. It seems like you have reached this point.

Your school has every right to report this parent for suspected abuse / medical neglect. In fact, it is your duty to report it! You only need suspicion and not proof. Who knows, this might remedy the situation.

Might advice is to collaborate with everyone involved and try as many evidence-based interventions (such as offering the bathroom every 1 1/2 - 2 hours) as possible. Trust me, you will need this paper trail to move forward. Document! Document! Document from the nurse's view, the teacher's, how it is affecting classroom / school environment, and most of all....the negative impact of the student! Make it as student (and not staff) focused as possible.

I know - in situations such as these, it feels as if you are walking in quicksand - but, hang in there. Good luck!

That's what I think I haven't made clear in this discussion. He does not have a 504 plan nor does he have an IEP. We are meeting with mother tomorrow afternoon and I'm hoping that we will draw one up with her! If she refuses a plan, which I see her doing, what measures could the school then take?

Thank you so much for your expertise. I really have no experience at all with 504's. My school unfortunately leaves me out of IEP meetings and the such. I've ask to come in on some meetings with my students I see on a daily basis. My school has went so long without real nursing support they don't know how to act since they've gotten one in that cares!

Cowgirl

Is the school psychologist and or school counselor going to be a party to the plan? Are they a part of this Section 504 team? I am hoping so. I personally would want their expertise to design the behavior plan. School nurses typically do not have the background for this type of issue. I don't.

Suggestions, approach the totality of the issue with the soiling / wetting consequences as an offshoot of the bigger issue, the child's health and diagnosis.

Be sensitive to mom. Support her and support the child. If you are all are frustrated, can you imagine how she feels?

Try to avoid using the term"noncompliant" or other emotionally charged terms. Try to be positive. Expect a team positive approach. Expect mom to be positive. Use all of the therapuetic communication in your orificenal. "I can see this has been frustrating...you are worried about your child....you do not know what is best...." Show mom that you are sensitive to the the child's embarrassment and humiliation and have a plan to avoid that and any school action that could trigger bullying.

Try to solve the child's problem and her problems first in the meeting. Then move on to how to solve the school's problems.

Good luck!!!!!!!!!!!!!!!!!!!!!!!!!! Let us know how it goes.

We are having a meeting with mom tomorrow hopefully to develop a 504 plan for this young man. Our asst. principal called our school psych yesterday so I'm hoping she will be there to help us along. I have absolutely no experience with the 504 plans either. This is the first time its came up since I've worked here. It's such an unusual problem I think we've all been confused on how to best solve this issue. My fear is mom is going to shoot down everything we suggest doing in the 504, such as changing clothes when wet, letting us know so we may help him better, etc. She wants him to go on without any assistance at all or to be made to change or clean up. We've had several instances with her where she will agree to something one day and the next day totally turn 180 and refuse it. That's where a signed plan will come in handy if we get her to agree. What will we do if a plan isnot made or she refuses all our suggestions? Where should we go from there?

Specializes in school nursing.

I would bring as much documentation as possible to the 504 meeting. Do your research - have an evidence based care plan ready for review. Show her why sitting in his urine causes skin breakdown (articles, textbooks, diagrams), teach her about bloodborne pathogens. Make sure you have your psychologist and school counselor at this meeting so that they can discuss emotional / social problems associated with the diagnosis.

Every person at the meeting will have to sign the 504 plan. The plan may be no plan because mom refuses - but you will have documentation! This will show that the school tried to do their part but mom flat out refused. I don't know about Illinois law - but could you even record the meeting?

Also, how are this student's grades? Is reading level on target? Does student have other medical / emotional / learning disabilities? Cognitively, is the student able to comprehend the consequences of sitting in urine / feces? Does this student need testing for special education services?

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