Policy Details

5141.25 FORM 7 Individualized Healthcare Plan (Middle/HS)

INDIVIDUALIZED HEALTHCARE PLAN (Middle/HS)
Student Name: ______________________________ Birth Date: ______________ Grade: __________ Teacher: _____________________________
Plan effective from 2006 to 2007
ASSESSMENT DATE/NURSE FUNCTIONAL HEALTH CONCERN STUDENT OBJECTIVE(S) INTERVENTIONS EVALUATION
Risk for life-threatening allergic response to allerge; history of asthma Student will remain free of allergic reactions to peanuts while in school 100% of the tiem by following the IHCP requirements, especially food refusal and advocating for himself/herself when allergens may be present in the environment. Parents will:
² inform school nurse and teacher of food allergy prior to the state of school each year.
² provide a physician's order and medicatin for medical intervention for the health office. Medication should not expire during the school year.
Student has an
Individualized Emergency
Care Plan (IECP) ² inform school nurse of any changes in health status as it relates to food allergy and treatment.
² educate student in the self-management of his/her food allergies appropriate for his/her age level.
Student will immediately initiate self administration of emergency medications OR immediately notify an adult and cooperate with staff administratin of emergency medications in the event of suspected ingestion of peanut 100% of the time.
² provide emergency contact information.
² meet with school nurse to develop an IECP and IHCP.
Nurse will:
² meet with parents and teacher to develop an IECP and IHCP.
² work with teacher to eliminate the use of allergen in classroom snacks, curriculum, educational tools, classroom parties, foreign language projects, and arts and crafts projects.
² educate school staff who interact with student regarding food allergy, and recognition of symptoms of allergic reactiosn, including local, general and anaphylactic types, with emphasis on recognition and emergency interventions for the latter.
² train certified personnel in EpiPen administration, as appropriate.
² develop and disseminate emergency care plan and transportation plan for student
INDIVIDUALIZED HEALTHCARE PLAN (Middle/HS)
Student Name: ______________________________ Birth Date: ______________ Grade: __________ Teacher: _____________________________
Plan effective from 2006 to 2007
ASSESSMENT DATE/NURSE FUNCTIONAL HEALTH CONCERN STUDENT OBJECTIVE(S) INTERVENTIONS EVALUATION
Nurse will: (continued)
² implement the IECP and direct emergency actions in the event of anaphylaxis.
² review with student, at least annually, his/her knowledge of the symptoms of anaphylaxis and skills needed for self-administration of an EpiPen, including practice in injecting an EpiPen into an orange.
Student will:
² not eat any foods at school, on field trips or in extracurricular activities that do not come from home or have not been approved by his/her parents.
² inform teacher/staff if he/she is not feeling well for any reason, but especially if he/she thinks he/she may be having an allergic reaction.
² [For student carrying their own medications] Follow the medication plan for self-administration of EpiPen and Benadryl. Accordingly, student will bring to and from school, and at all times carry (e.g., in belt-carrying case or in a purse) an up-to-date EpiPen and Benadryl, according to the physician's order. If a student chooses to keep emergency medications in her purse, she will keep the purse with her at all times in schook, during extracurricular activities, and on field trips.
² not self-administer Benadryl or EpiPen without immediately notifying the school nurse, or another responsible adult, in the absence of the school nurse.
INDIVIDUALIZED HEALTHCARE PLAN (Middle/HS)
Student Name: ______________________________ Birth Date: ______________ Grade: __________ Teacher: _____________________________
Plan effective from 2006 to 2007
ASSESSMENT DATE/NURSE FUNCTIONAL HEALTH CONCERN STUDENT OBJECTIVE(S) INTERVENTIONS EVALUATION
Student will: (continued)
² not keep any medication in his/her locker.
² participate with school nurse in review of emergency self-administration of medication plan and implementation skills.
School Nurse: _________________________________________ Date: _______________
Review by: Parent: _________________________ Date: _______________ Student: _________________________ Date: _______________


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