Barren River District Health Department

Site:______

Barren County Schools

Barren River District Health Department

Catherization Individualized Health Plan

Please fax back to:______

Student Name______Date of Birth______Classroom ______Hospital of Choice______

DIAGNOSIS:______

MEDICATIONS TO BE GIVEN AT SCHOOL: ______

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PRECAUTIONS AT SCHOOL: ______

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INTERVENTIONS TO BE PROVIDED AT SCHOOL:______

______

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RESTRICTIONS/EXCLUSIONS AT SCHOOL: ______

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OTHER COMMENTS: ______

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Urinary Catheterization Urethral Suprapubic

*All supplies and equipment are to be provided by the parent/guardian.

Times for procedure (Be Specific): ______

Recommended position:______

If questions regarding catheterization times, may we contact the parent/guardian for

decision?____ Yes ____No

Can this student catheterize him or herself?____Yes Independently ___NO Adult Assistance

Typical characteristics of student’s urine: ___Clear ____ Cloudy ____ Odor ____Typically has blood

Typical color and amount of output:______

Encourage water throughout day ______Yes ______No ______Amount______

EMERGENCY PLAN OF ACTION FOR ALL STAFF:

1. Notify parent if fever, strong smelling urine, abdominal pain, pain or swelling at cath site, urine that is dark red pink or cloudy, bleeding or pinkish discharge before or after procedure.

2. When any changes in the student’s typical characteristics are observed, THE PARENT/GUARDIAN MUST BE NOTIFIED IMMEDIATELY. If necessary, call 911.

3. Notify school personnel trained in CPR/first aid to stay with student and initiate CPR if needed prior to EMS arrival.

4. If EMS is called student must be transported via EMS to emergency facility, or parent/guardian must sign release with EMS and parent/guardian then assumes responsibility for student. Student may not return to school that day.

5. When student is transported via EMS a staff member must accompany the student unless parent and/or emergency contact accompanies them.

6.Other: ______

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This order and plan of care is valid for current school year. Parent must supply all ostomy/ cath supplies, snacks, special needs equipment.

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PRINTED NAME OF PHYSICIAN/ ARNP PHONE NUMBER DATE

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SIGNATURE OF PHYSICIAN/ ARNP FAX NUMBER

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ADDRESS OF PHYSICIAN

I give permission for (name of child) ______to receive the above stated medication(s) at school according to standard school policy and expressly hold harmless and waive any liability on behalf of, the Barren County School District / Barren River District Health Department or either of its employees and agents concerning any injuries or reactions resulting from the administration of the above medication unless such is the result of negligence or misconduct on behalf of the school or its employee.

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Parent Signature Phone Number Date

Reviewed by School Nurse______

Copy to Pertinent school staff______

Copy to District Nurse______

(4-2014)BC 6A-3