DISTRICT



SAMPLE DIABETES Individual Health Care Plan (IHP) Page _____ of _____

For health needs that may result in an emergency and/or need management or monitoring.

Student Name:___________________________________ Medical Diagnosis: Part of IEP: Yes No

School: Date Initiated:

Grade: _____________________________ Health Care Provider: By:

Date Reviewed:

By:

Underline areas of concern: Medical management, dental management, safety, vital functions, elimination, mobility, rest, comfort.

NURSING ASSESSMENT NURSING DIAGNOSIS NURSING INTERVENTIONS EVALUATION

The school nurse will: Student Outcomes- The student will:

|The student is very knowledgeable regarding their |High Risk for Physiological Injury due to development of |Hypoglycemic Management (NIC 2G –2130) |1. ____will recognize and treat early signs of |

|diabetes management. They most often can recognize |acute complications related to hypoglycemia (low blood |Activities: |hypoglycemia appropriately and know how to |

|hypoglycemic states. Their primary symptom of low |sugar) or ketoacidosis (high blood sugar) (NANDA 1.6.1) |School nurse will develop– emergency action plan - and |recognize and respond to early signs of |

|glucose levels is being belligerent. They have a | |instruct staff in how to respond to low blood sugar |ketoacidosis. |

|very supportive family. They manage their blood | |levels |2. ____ will manage or have assistance managing |

|sugar with and insulin pump and continuous glucose | |School nurse will observe _____- check his blood sugar |hypoglycemic reactions. |

|monitor. | |levels bi-weekly. |3. ___ will have minimal low blood sugar |

| | | |reactions in school. |

| | |Hyperglycemia Management (NIC 2G – 2120) | |

| | |Activities: | |

| | |School nurse will train staff and supervise student in | |

| | |administration of insulin. | |

| | |School nurse will observe ____ self-administer insulin | |

| | |bi-weekly. | |

Page _____ of ____

OUTCOME: Risk Control (NOC IV-T-1902)

|Indicators |Never Demonstrated 1 |Rarely Demonstrated 2 |Sometimes Demonstrated 3 |Often Demonstrated 4 |Consistently Demonstrated 5 |

|____ recognizes own low blood sugar| | | | | |

|reactions | | | | | |

|Staff follows emergency care plan | | | | | |

|_____ monitors own blood glucose | | | | | |

|levels | | | | | |

| | | | | | |

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