Individualized Health Care Plan School Year: 2016/2017
Student's Name: DOB: Age: School Site:
Parent Name: Contact #: Date of IHCP: Physician: Phone: Fax: NA Specialist: NA Phone: NA Fax: NA Diagnosis & Health History: Asthma is an allergic disorder characterized by spasms of the bronchi (the airway tubes); swelling of the mucus lining of the lungs; and excessive production of a thick, viscous mucus. The major concern with asthma is that it can lead to respiratory failure-the inability to breathe. Symptoms include episodes of wheezing, coughing, chest tightness, and shortness of breath. Episodes may occur a few times a day, or a few times a week. They can be recurrent or seasonal. Depending on the person symptoms may become worse at night, with exercise or when exposed to air pollutions. Medications: Nursing By Diagnosis / Educational Goal Plan of Action Whom/When Concern Potential for Student will maintain 1. Monitor For The Following Symptoms of Asthma/Respiratory Distress: School nurse respiratory health and well-being • Persistent coughing • Flaring nostrils Adm. Staff distress necessary for • Clearing throat • Chest/clavicular retractions Teaching staff learning. • Difficulty or rapid breathing • Anxiety, apprehension, panic Ancillary staff • Only able to speak in one or two word • Bluish color around lips and/or eyes Ongoing sentences Complaints of chest tightness • Audible wheezing Potential Maintain optimal 2. Responding To Student With Symptoms of Asthma Attack/Respiratory Distress: need for pulmonary function • If ordered by healthcare provider, student may carry and self-administer medication medication • If symptoms do not significantly improve in 5 minutes notify office staff, Health Services management • If medication kept in office, accompany student to office to use medication. of asthma Potential for Student will 3. Monitoring Student with ACUTE Respiratory Distress change in maintain health and • Acute Respiratory Distress is a MEDICAL EMERGENCY medical well-being necessary • CALL 911 – Notify Office Staff to Call Health Services & Call Parents status for learning. • Staff with student, encourage taking slow breaths and prolonging exhaling Potential for Student will 4. Essential for Safety of Student knowledge understand asthma • Ensure student has inhaler (that is not expired) at school or on person deficit R.T. management to • Ensure student knows how and when to properly use inhaler asthma & its allow self-monitor & • Student with inhaler who is short of breath will be instructed to inform teacher/office staff management care of the disease
1 Individualized Health Care Plan School Year: 2016/2017
Nursing Diagnosis/Concern Educational Plan of Action By Whom/When
Goal The Individual Health Plan (IHP) will be reviewed The IHP will be IHP team annually with the parent as well as appropriate staff updated/revised Review RN Parent UAP Principal Annually members. This plan may be revised/updated as annually to Date: Initials: Initials: Initials: Initials: appropriate to ensure the most current treatment meet the health modalities for the student. The school nurse will train needs of the and supervise all non-medically licensed school student personnel who are delegated responsibility for implementing any portion of this plan as appropriate.
Parent Signature: Date: Principal Signature: Date:
School Nurse Signature: Date: Staff Signature: Date:
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