You are on page 1of 2

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:

You might also like