Individualized Health Care Plan Planning Form

Demographics

Student Name _Jane Doe_______________________________________________ Birth Date _05/17/2009_______

Home Address _555 Street, City, State 55555______ ___________________________________________________

Parent/Guardian __MOM__________________________________________________ Phone 333-333-3333______

Parent/Guardian __DAD__________________________________________________ Phone 222-222-2222_____

Caregiver ___Parents_______________________________________________________ Phone _________________

Language spoken at home _English____________________

Emergency Contact: _MOM___________________________________ _Mother___________________ _333-333-3333______

Name Relationship Phone

Medical Care Primary Physician _Dr. Doctor__________________________________ Phone _555-555-5555________

Specialty Physician_Dr. Special Doctor_______________________________________________ Phone 444-444-4444_

Health History

Brief health history

_Jane has a history of moderate persistent asthma and seasonal allergies.___________________________________________________

Special health care needs

Jane needs access to her albuterol rescue inhaler at all times. _________________________________________________________

Other considerations

Jane may need help identifying when she needs her inhaler. Jane may also need assistance properly administering her medication.__________

Student’s Ability to Participate in Care

Jane may request her inhaler if she feels she needs it. Jane will need to be observed while administering her medication to make sure she is
administering it correctly._________________________________________________________________

Allergies

Seasonal________________________________________________________________________________________________________

Medication & Dietary Needs

Current Medications (dose, route, time, special considerations)

Albuterol HFA 2 PUFFS Inhalation every 4 hours as needed for cough, wheeze, or shortness of breath

Albuterol HFA 2 PUFFS Inhalation 15-20 minutes prior to physical activity

Albuterol HFA 4 PUFFS Inhalation every 15 minutes for respiratory distress. Call 911 if not providing relief of symptoms after second round of 4
puffs.

ALWAYS USE SPACER WITH ALBUTEROL

Special Dietary Requirements

_N/A________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________

Procedures

Procedure Administration of albuterol_________________________________________________________

Frequency Every four hours as needed__________________________________ Times As needed____________________________________

Position of student during procedure Sitting or standing________________________________________________________

Ability of student to assist/perform procedure

Jane may perform procedure with observation and assistance_____________________________________

Location for procedure Nurse’s office________________________________________________________________________

Equipment needed

Inhaler and spacer_____________________________________________________________________

__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________

Procedural considerations & precautions N/A________________________________________________________________________________

__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________

Staff qualified/trained to assist with procedure

School nurse, Jane, and school secretary__________________________________

__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________

Medical Orders for Specialized Health Care Procedures

Student Name Jane Doe_____________________________________ Birth Date _5/17/2009_____________ ______________________

Home Address 555 Street, City, State 55555_____________________________________________________

Name/description of specialized health care procedure

__Albuterol administration prior to exercise and as needed for cough, wheeze, or shortness of breath.

Time or indication for procedure

_As needed prior to exercise and for cough, wheeze, or shortness of breath.

Precautions, potential complications & needed actions

Jane may experience tremors, increased heart rate, or a feeling of “shakiness.” This is normal after albuterol administration and will pass.
Person(s) authorized to perform procedure

__X_ School Nurse _X (school secretary) Trained School Staff _X__ Student

Transportation Plan for Student with Special Health Care Needs

Student Name- Jane Doe_______________________________________ Class/Grade _3rd_______ Parent MOM_________

Phone 333-333-3333____ Period From _2019___ To _2020___ Review Date _08/15/2019______

1. Adaptations/Accommodations Required
_____ Transportation Aide _____ Bus lift _____ Seat belt _____ Special restraint _____ Wheelchair tie down
Space for equipment: bag for asthma supplies______________________________________________________
________________________________________________________________________________
2. Positioning or Handling Requirements
__X___ None _____ Describe _____________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
3. Behavior Considerations
__X___ None _____ Describe _____________________________________________________________________________________
____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
 Individualized Healthcare Plan
Student Name: _Jane Doe____________________________________ DOB:_5/17/2009_______ School:__A Elementary___________
Grade:__3rd_____

Summary of Health Condition: Well controlled moderate persistent asthma and seasonal allergies requiring albuterol use prior to exercise, and as
needed for cough, wheeze, and shortness of breath.

Plan effective from 2019 to 2020

Date Health Need Student Goals Interventions Outcomes Evaluation/Progress

(Nursing Dx) Notes
8/15/19 Deficient knowledge of Short Term: - Assess patient’s current - Student will be - Have student
disease process - Student will knowledge of asthma empowered, and verbally
(asthma) related to lack correctly identify and rescue medications. become safer and teachback times
of information sources times when - Educate student about more capable to when rescue
as evidenced by rescue inhaler is warning signs of an provide self care. inhaler may be
ineffective self care. needed. asthma exacerbation. - Student will be needed.
Long Term: - Educate student about able to self carry - Have student
- Student will asthma triggers. albuterol for next perform use of
independently - Educate student about school year. albuterol with
and correct use of rescue spacer with out
appropriately inhaler and spacer. assistance.
administer - Reinforce need for
rescue inhaler consistent use of daily
with spacer. medications, and
appropriate use of
rescue medications.
- Reinforce what to do if
student believes she is
suffering from an
asthma exacerbation.
8/15/19 Activity intolerance Short Term: - Educate student on use - Student will - Evaluate if
related to airway - Student will be and effects of albuterol. engage in normal student will come
problem as evidenced compliant with - Demonstrate correct activities with out to nurse’s office
by inability to speak, administration use of albuterol HFA presence of to receive
eat, play. of albuterol with spacer for student. asthma symptoms. albuterol
prior to exercise. Have student teachback treatment prior
 via demonstration. to exercise
- Develop plan of care unprompted by
with student, and nurse or teacher.
provide rewards to
reinforce compliance
with plan.

Nurse Signature Initials

HALEY WHITE, RN HW
 Daily Log

Student Name _Jane Doe____________________________ Class/Grade ______3rd____________________________________

Procedure _Albuterol Administration_______________________________

Parent _MOM____________________________________ Phone _333-333-3333_______________________________

Date/Time Procedure notes Observations Time for Prep, Completed by

Proc, Doc

Nurse Signature Initials Nurse Signature Initials