Right to refuse?

[nursekoll, BSN, RN]

High school age, wheelchair-bound student with incontinence, unable to physically reposition self in chair during school day. Prior to this year, the student was being changed once or twice a day by two trained school staff with use of a manual Hoyer lift to a padded trainer table in a private bathroom area. This year student has started refusing being changed. Student states discomfort with lift sling and also denies need, as sometimes student is not wet or not very wet at scheduled time of changing. Physical therapist has brought concerns to me about skin integrity and sitting in power chair all day with no pressure relief of skin and possibly wet skin for good part of the school day. PT has asked me to do weekly skin assessments for skin integrity and breakdown prevention. Student does have a gel pad on the power chair seat.

How do I validate the student's right to refuse and also fulfill my requirement to assess skin integrity and provide interventions to prevent breakdown at school?

Parent seems OK with student's refusal and parent changes the student's incontinence brief at home before and after school. Is this enough? Can I document this and ask that parent will bring any skin concerns to my attention? What do I tell the PT?

I believe part of the refusal is also related to the student's age and general teenage rebellion/embarrassment about being changed. Also the student likely is not drinking enough water/liquids in order to not be wet or very wet though the day. The student rarely has a BM at school.  (I am the only nurse in the district and am not in the high school building daily, so I have trained paras to assist with this student's ADL's)

Thoughts.....

[beachynurse, ASN, BSN]

This is a tough one. I am concerned as well about his skin integrity without being changed. However, he does have the right to refuse. I would talk to the parents and express your concerns. If they still feel as though it is OK for him not to be changed during the school day, I would get something in writing from the parents, and get a release of information so you can communicate with his MD. 

I am a high school nurse as well, these are challenging years for these teens. 

[NutmeggeRN, BSN]

How about a condom catheter with a leg bag? The old Texas Catheter? Can be applied at home and the leg bag can be under his pants. Then he can drink more (which would be better and it ti s only the drainage of the bag, Would he be able to do that independently? And if not, srill way less invasive of privacy.

[ValLyn]

I like the previous idea of using a condom cath with leg bag. He needs more education, verbal and visual.  Parents need to be educated as well. Even though he may have the pillow and cath, he and the parents need to know that constant pressure also causes skin breakdown. Make sure to document the education and, after the plan has been implemented, the follow-up.