Diapering and Toileting Considerations

Elimination

Students may require diapering or help toileting due to developmental level, health concerns, or physical or cognitive disabilities. These students may require diapering or toileting on a scheduled or on an “as needed” basis. Students who require diapering or assistance with toileting should be treated with respect and cared for in a private, safe, and clean setting. Students cannot be denied entry into or removed from any educational program if they have not mastered this skill.

Staff involved in changing diapers or toileting have the potential to spread germs and diseases. School administration, in collaboration with the school nurse, should develop procedures and protocols for staff to follow to help reduce the risk of transmitting germs and diseases.

School nurses should not be routinely used for changing diapers or assisting with toileting as it takes time away from the nursing responsibilities that require a nurse’s professional knowledge, input, skills, and abilities. Assistive personnel are the ideal staff members for performing activities of daily living–such as toileting. See Managing Encopresis in Schools (5-page pdf).

The following list of considerations can assist school districts in developing policies, procedures, and protocols related to diapering and toileting students.

Student:

Are students required to wear a barrier garment (brief/diaper) for any periodic incontinence?
How long must a student be “accident free”, or under what conditions, before allowing them to be without a brief/diaper?
Does the student have a health condition that will require ongoing assistance related to toileting?
If the student does not have a diagnosed health condition, does the student have a progress plan to become continent that will require ongoing assistance?

Documentation:

Documentation of parental/guardian approval should be acquired prior to performing diaper changes or assisting the student with toileting at school.
Is the need for toileting/diapering included in the student’s 504 or IEP as an accommodation?
- If yes, is there any additional information or documentation that is required?
  - i.e., who is assigned to assist the student with toileting
- Where should the additional information be documented
Will staff be allowed to apply ointment, creams, or lotions to the student’s genital area (i.e., diaper cream)?
- If yes, written authorization from parent/guardian should be acquired
  - Parent/guardian authorization form should include:
    - Name of the over the counter (OTC) ointment/cream/lotion
    - Instructions on how and where to apply
    - Instructions on when/how often the ointment/cream/lotion should be applied.
If the ointment, cream, or lotion requires a prescription, an order from a health care provider is required.

Health care provider’s order should include:
- Student’s name
- Date of birth
- Name of medication
- Dose of medication
- Route of application
- Time of application
- Reason for application
If school district policy requires health care provider order for OTC medications, then health care order would be required
Does the school district policy require staff to complete a medication administration training and competency validation?
What information regarding the diaper change/toileting procedure should be documented?
- Where should the information be documented?

School Staff:

Which staff will be allowed to change a student’s diaper and assist students with toileting?
Will staff who are responsible for food preparation be allowed to change a student’s diaper or assist the student with toileting?
- If yes, what additional infection prevention measures will be required?
Will more than one staff person be required to be present during diaper change or assisting with toileting?
- If yes, what additional planning and resource allocation (staff) will be required to ensure this requirement is achievable and met?
- If the policy/procedure/protocol indicates that two staff be present it is highly recommended that two staff are always present. Not having two staff present will increase liability.
- Second staff person should be present for the entire time it takes to complete the procedure.
- If it is not possible to have two staff members present, consider using a bathroom that is in sight and/or audio vicinity of other adults.
Will staff not involved in the diapering procedure be allowed to be in the room when the procedure is being performed?
Will staff responsible for changing the student’s diaper or assisting the student with toileting be required to be the same gender as the student?
- If yes, what additional planning and resource allocation (staff) will be required to ensure this requirement is achievable and met?

Field Trip:

Trained staff should accompany the student on field trips

If school policy requires two staff persons or staff who are the same gender as the student to assist with toileting and/or diaper changes this applies to field trips as well
- What additional supplies may be needed on a field trip?

Supplies:

Who is responsible for providing diapers, wipes, change of clothing, and other required supplies?
Who is responsible for providing personal protective equipment (PPE) (i.e., gloves) and cleaners/wipes for changing area?
Where will the supplies be stored?
- Individual student diapering/toileting supplies
- Cleaning supplies
  - Should be stored out of the reach of children.

Training and Education:

What training or education will be required of/provided to school staff who will be changing diapers or assisting in toileting?
- Diaper change procedure
- Toileting procedure
- Ensuring student privacy
- Bloodborne pathogen training
- Proper body mechanics
- How to properly transfer the student on to the toilet or changing area
  - This could include the use of assistive devices (i.e., wheelchair, slide bar, grab bar, etc.)
- Report any student body fluid exposure to appropriate school personnel
- Documentation requirements
- Medication administration training and competency validation
- Signs and symptoms to be reported to the parent and/or nurse
What steps will staff be permitted to perform?
- Assist the student in removing soiled clothing
- Assist the student in putting on clean clothes
- Assist the student with wiping their genitals and buttocks
  - Staff should be instructed to wipe genital area from front to back
- Applying diaper ointment/cream/lotion to genital area
Who is responsible for providing staff training and education?

Infection Prevention Measures:

Are there any infection prevention requirements for staff?
- Hepatitis A and B vaccines
- Yearly bloodborne pathogen training
- Training on proper disposal of contaminated items
What cleaning supplies will be used to clean diaper changing area(s)?

Procedure:

1. The diapering procedure should be written and include action steps school staff should take.

Important instructions to include in procedure:

Ensuring student privacy
Explain to the student what you will be doing (see Communication)
Perform hand hygiene before and after diaper change and after cleaning diaper change area
How to properly transfer the student on to the toilet or changing area
- This could include the use of assistive devices (i.e., wheelchair, slide bar, grab bar, etc.)
Use appropriate PPE (i.e., gloves)
Have the student perform hand hygiene after diaper change
Do not leave student unattended on the changing table/area
Have supplies within reach when performing the procedure
If applying diaper ointment/cream/lotion, how to apply without contaminating the container/tube
Use proper body mechanics
Clean diaper changing area after each use, per school district procedure
- Put on clean gloves prior to cleaning to prevent cross-contamination
Report all concerns to the appropriate people
Document procedure as instructed by school district policy
Report any student body fluid exposure to appropriate school personnel

2. The toileting procedure should be written and include action steps school staff to take.

Important instruction to include in the procedure:

Ensuring student privacy
Explain to the student what you will be doing (see Communication)
Perform hand hygiene before and after assisting the student with toileting
Use appropriate PPE (i.e., gloves)
Have the student perform hand hygiene after toileting
Inform the student that you will be assisting with wiping before you begin
Use proper body mechanics
Report all concerns to the appropriate people
Document the procedure as instructed by school district policy
Report any student body fluid exposure to appropriate school personnel

3. Where will the diapering be performed?

Is the space large enough to accommodate:

The student
School staff (especially if more than one are required)
Supplies
Mobility equipment (i.e., mechanical lift, wheelchair)

4. Does the space designated for diaper changes have access to running water?

School staff should perform hand hygiene before and after performing the procedure, even when using gloves.

5. Where should soiled clothing be placed?

Communication:

1. What information should be communicated with the student prior to beginning the diaper change or toileting?

Staff should treat students with dignity and respect and model boundaries by telling students when and why they are touching the student’s private areas.

2. Procedure should indicate the following:

Student should not be left unattended on table or countertop
How often staff should check student’s diaper
- I.e., every two hours, when student wakes up from nap, before the student leaves at the end of the school day
That diaper should be changed when the diaper is wet/soiled

3. What information will be communicated to parents/guardians?

Times when diaper was changed/when student was assisted with toileting
Presence of foul-smelling urine
Change in color of urine
Student complaining of pain with urination or stooling
Any change in urine or stooling pattern
Rashes or skin break down

4. How often will parents receive communication?

5. How will parents receive the communication?

6. What information should be communicated to the school nurse (i.e., foul smelling urine, change in color of urine, student complaining of pain with urination or stooling)?

7. What information should be communicated to the school administrator (i.e., signs of abuse)?

Resources

Autism Speaks: Parent’s Guide to Toilet Training: https://www.autismspeaks.org/sites/default/files/2018-08/Toilet%20Training%20Guide.pdf

CDC Diaper Changing Steps: https://www.cdc.gov/hygiene/childcare/childcare.html

Maine Department of Education: Toileting Support Resource https://www.maine.gov/doe/sites/maine.gov.doe/files/inline-files/TOILETING%20RESOURCE%20FINAL.10.13.2022.pdf

GUIDE: Best Practices in School-Based Toilet-Learning & Continence: https://cdci.w3.uvm.edu/blog/continence/2022/08/08/guide-best-practices-in-school-based-toilet-learning-continence/

Toilet Learning in School: https://cdci.w3.uvm.edu/blog/continence/category/toilet-learning-in-schools/

Acknowledgement of Reviewers

Renee Falkner, BSN, RN
School Nurse Supervision Specialist | Therapylog

Katherine Park, DNP, RN, NCSN
Nationally Certified School Nurse, Pierremont Elementary
Adjunct Professor, Maryville University School of Nursing

Updated 4/15/2025

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