MEDICAL PROTOCOLS
SHUNT CARE PROTOCOL
Child’s Name: / Birthdate:Parent/Guardian: / Home Phone:
Address: / Work Phone:
Additional Info: / Cell Phone:
Physician Treating Student for Shunt: / Work Phone:
Protocol Written By: / Date:
A shunt is placed into a child’s head to direct the flow of excess cerebrospinal fluid (CSF) from the ventricles (spaces in the brain) to another place in the body where it can be absorbed into the bloodstream. There are two types of shunts:
A VP (ventriculo-peritoneal) shunt that moves CSF from the ventricles to a space in the peritoneal cavity inside the abdomen.
A VA (ventriculo-atrial) shunt that moves CSF from the ventricles into the atrium (top chamber of the heart) through a vein in the neck.
Special Activity Instructions: (Always protect from blows to the head, neck, and abdomen) ______
______
______
If Student Exhibits:
a. Persistent irritability / h. Deterioration of school performanceb. Change in personality / i. Fever
c. Headache / j. Nausea/Vomiting
d. Stomach ache / k. Rapid jerking or movement of eyes (nystagmus)
e. Lethargy / l. Unequal pupils
f. Dizziness / m. Change in gait
g. Blurred Vision
Do the following:
1. Call parent and report symptoms.
If student becomes unconscious or has seizure, do the following:
1. Call 911 immediately.
2. Notify Parent.
If student receives any blow to the head , neck, or abdomen, do the following:
1. Report promptly to parent.
2. Monitor student through remainder of school day for any signs listed above; if noted, immediately advise parent.
3. Do not allow student to walk home/drive self/ ride bus if blow to head has occurred in preceding one hour and/or student has any symptoms listed above.
SIGNATURES:Parent: / Date:
Teacher: / Date:
Service Coordinator : / Date:
EI/ECSE Nurse: / Date:
This authorization expires on ______(not to exceed one year from the date of signature above).
(Month/Day/Year)
______
For Office Use: Copies To: Parent EI/ECSE Nurse Transportation Office
Physician EI/ECSE Office Other ______
EI/ECSE Forms 10-2006