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Iowa Individual Health Plan: Interpretive Statement

Iowa Individual Health Plan (IHP): Interpretive Statement

The Individual Health Plan (IHP) is a comprehensive plan outlining the provision of student health services leading to the achievement of desired student outcomes. It is recommended the IHP use standardized nursing language such as NANDA, NIC, NOC, and others.2,5,11,12,16 The IHP is a written guide to school health services provided for both special and general education students with health impairments. The IHP is a modified version of the traditional nursing care plan incorporating all parts: assessment, diagnosis, goal setting, intervention, and evaluation of outcomes. It is used to communicate the provision of professional nursing services, detail the systematic individualized nursing process, and document student health needs. The registered school nurse (family physician in districts without a school nurse) develops the plan in association with the student, family, health care provider, and school team. The written IHP is kept in the health record and integrated into the Individualized Education Program, Individualized Family Service Plan,10 or Section 504 plan as specified by area and district policy. The Iowa Code, Iowa Administrative Code, and the Standards of Professional School Nursing Practice govern this process.8,9,14 Discussion of the components and example formats follow.

Assessment

Nursing assessment is the process used to determine the student's present health status. Sources of information for the student health assessment include, but are not limited to: interviews with student and family; review of the student health record, medical records, health history, physical assessments and measurements; developmental and or family assessments, and other previous assessments; and systematic observations by other school professionals. The school nurse interprets the information using professional knowledge and expertise6 to indicate how the child's health status affects their educational performance and to determine the appropriate nursing diagnoses.

Nursing Diagnosis

Nursing diagnoses are derived from the assessment data and based on critically analyzed evidence to confirm the presence and specific nature of the health need. "Nursing diagnosis is a clinical judgment about an individual, family, or community response to a health problem or life process. Nursing diagnosis provides direction for interventions to achieve outcomes for which the nurse is accountable."16 It is composed of at least a diagnostic label and related factors. By using standardized language16 for the definitions and diagnostic classifications of the nursing diagnosis, the school nurse appropriately labels health status for the individual health plan and the Individualized Education Plan.5

Student Goals

Goals are derived from the nursing diagnosis and direct the planning of nursing care and priorities for action.9,18 Goals are broad statements to describe the attainment of a higher level of student health status.18 A well-written goal is meaningful, measurable, able to be monitored, and useful in making decisions.10 When setting goals, it is important to prioritize needs according to the level of urgency.12,13 The school nurse must also consider the value of the goal to the student and family and the impact of goal achievement on the student's school performance.

Interventions

Interventions originate from the nursing diagnoses, student goals, and expected outcomes. When planning interventions the nurse considers the educational implications and selects nursing actions that support the student's physiological, behavioral, safety, family, and health system functioning. The components of an intervention statement include therapeutic actions done with the student, the qualified designated personnel completing the action, and how frequently the action occurs. Actions may include both direct care provided to a student (e.g., Seizure Management, Medication Administration, and Emergency Care) or indirect care provided on behalf of the student (e.g., Delegation, Documentation, and Health Care Information Exchange).11

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Iowa Individual Health Plan: Interpretive Statement

Interventions that support the provision of special health services8 require additional documentation in the student file. This documentation includes but is not limited to the following: a written prescriber order, a signed parent request for provision of special health services, rationale for delegation,9 specific procedures or protocols for delegated activities, and a written record of completed interventions.8 When an emergency health plan (EHP) is needed for a student with a life threatening condition, it is written either directly in the intervention portion of the IHP or in a separate document. If a separate document is used it is referenced in the IHP.

Evaluation

During evaluation the school nurse analyzes the student's response to nursing interventions and progress toward identified goals.12 Data collected during systematic ongoing evaluation is documented in the IHP and used to make decisions about modifications, additions, or deletions to the IHP. The school nurse reviews the IHP in collaboration with the student, family, and school team whenever the student's health status changes or at least annually.

Summary

The written collaborative coordinated Individual Health Plan documents the student's needs for school health services, the steps of the nursing process, and student outcomes to promote student health, prevent disease, and enhance school performance.14

Examples

Example formats follow illustrating various ways of writing IHPs and an EHP.

Iowa Expert School Nurse Committee

The Committee of Iowa Expert School Nurses developed the Iowa Individual Health Plan (IHP): Interpretive Statement, 1998-1999. Committee members included Debbie Brown, Melanie Hicklin, Marilyn Kinne, Julie Lambert, Patrice Lambert, Dody Olson, Lois Pavelka, Marilyn Peasley, Susan Poulton, Sondra Price, Pearl Scherrman, Rhoda Shepherd, MaryAnn Strawhacker, Sharon Stewart, Marilyn Wilbright, and Charlotte Burt. 12/99

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Iowa Individual Health Plan: Interpretive Statement

Example Individualized Healthcare Plan using Standardized Language

Student name: Birthdate: School: Effective date: Physician: School nurse: Assessment data: Nonambulatory, 6-year-old female requiring clean intermittent catheterization five times per

day (two times at school), interested in helping with procedure but unable to do independently because of uncoordinated fine motor skills. On medication to promote dryness between catheterizations. Frequent urinary tract infections over the summer. Prone to constipation. Latex allergy.

Nursing diagnosis #1: Altered urinary elimination related to neurogenic bladder secondary to spina bifida (1.3.2

NANDA).

Student Outcome Goals:

1. (Student name) will remain dry between catheterizations 50% of the time during the school year. 2. (Student name) will begin to participate in intermittent catheterization program during the school year by recording amount of urine obtained with each catheterization and setting up supplies. 3. (Student name) will have decreased number of urinary tract infections during the school year.

Outcomes: Urinary Continence (2F-0502 NOC)

Never Indicators

Free urine leakage between catheterizations Sets up catheterization supplies Records urine amount in log Absence urinary tract infection Demonstrated 1

Rarely

Demonstrated 2

Sometimes

Demonstrated 3

Often

Demonstrated 4

Consistently

Demonstrated 5

Interventions: Urinary catheterization: Intermittent (1B-0582 NIC)

· Catheterize _______ at 10:00 am and 2:00 pm in health office (procedure attached) (Associate am, Nurse pm) · Assist _______ in setting up supplies at each catheterization, as appropriate (Associate, Nurse) · Administer Ditropan at 2:00 pm (Nurse) · Review signs and symptoms of urinary tract infection with student every month (Nurse) · Document amount of urine obtained at each catheterization in student's log (Student/Associate/Nurse) · Document if wet or dry before catheterizing (Associate/Nurse) · Report any changes in urine volume or wet/dry status to parent/physician (Nurse) · Report signs/symptoms of urinary tract infection to parent/physician (Nurse) · Check catheterization supplies and need for more/new supplies daily (Associate/Nurse) Delegation (6a-7650 NIC) · Teach associate to do catheterization procedure at the beginning of school year (Nurse) · Review procedure with associate every two months (Nurse) · Teach associate the signs and symptoms of urinary tract infection (Nurse) Multidisciplinary Care Conference (6b-8020 NIC): Activities · Report to IHP and IEP teams at scheduled meetings (Nurse) · Report any changes or problems to team members, as appropriate (Nurse) · Report to parents and health care providers regularly (Nurse) · Review progress toward attainment of student outcome goals regularly (Nurse)

Repeat for each additional Nursing Diagnosis Evaluation of actual outcomes:

Scheduled review dates

1) 2) 3) 4)

Accomplished

Yes No

Comments

I have read and approve of the above plan for school health care: Parent signature______________________ Physician signature (optional)____________________ Nurse signature_______________________ Date reviewed by the educational team_____________ Denehy, J., & Poulton, S. (1999). The use of standardized language in individualized healthcare plans. Journal of School Nursing, 15, 38-45.5

Page 4 of 8 Example Individual Student Health Plan Last Name: School District: First Name:

Iowa Individual Health Plan: Interpretive Statement

Birth Date: Written By:

Age:

Date Written:

Nursing Diagnosis: Risk for injury (NANDA 1.6.1) related to uncontrolled movements of seizures Assessment · Diagnosed with complex partial seizures at 4 years of age · Records reveal unknown etiology for seizures · Longest seizure free interval was 6 months last year · Most recent seizure was _______, lasting 4 minutes. No change in color observed. Resolved spontaneously · No other chronic conditions · Depakene currently prescribed. Last blood levels drawn _______ · Parents report ______ doesn't like to take medication and "will not tell anyone if not feeling well" Goals ______ will progress on the NOC Risk Control rating scale from a baseline score of 6 to a score of 15 by the completion of the _____ school year Interventions Seizure Precautions (NIC 2690) · Obtain signed release of information to facilitate communication with physician's office · Monitor drug regimen by monthly written communication with physician · Instruct ______ about Depakene's actions as well as potential side effects · Instruct ______ to notify school nurse if experiencing any unusual symptoms · Assist ______ and family in obtaining a medicalert bracelet · Write a seizure emergency plan with adaptations for field trips Delegation (NIC 7650) · Consult with primary caregiver and physician to assist in determining ____'s level of care required at school as a result of seizure disorder · Identify and modify possible environmental safety hazards should a seizure occur · Evaluate the complexity of care delegated and the predictability of outcomes · Instruct designated personnel yearly in first aid for seizures, documentation of seizure activity, and use of ______ emergency plan · Evaluate building emergency team's response time and understanding of _____'s emergency plan during a yearly practice session By Whom School Nurse Student Outcomes Risk Control (NOC) 1=Never demonstrated 2=Rarely 3=Sometimes 4=Often 5=Consistently Indicators: · ______ monitors environmental risk factors 1 2 3 4 5 · _______ acknowledges risk factors 1 2 3 4 5 · ______ recognizes changes in health status 1 2 3 4 5 · ______ monitors personal behavioral risk factors 1 2 3 4 5 · ______ complies with treatment regimen 1 2 3 4 5 Baseline rating completed _________ (date)

School Nurse

Strawhacker, MaryAnn. (1999). Individual student health plan: Risk for injury. Johnston, IA: Heartland Area Education Agency 11.

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Iowa Individual Health Plan: Interpretive Statement

Example Individualized Healthcare Plan

Name: Address: Home Phone: Parent/Guardian: Day/Work Phone: Healthcare Provider: Provider's Phone: IHP Written by: Birthdate: School: Teacher/Counselor: Grade: IHP Date: IEP Date: Review Dates: ICD-9 Codes:

Assessment Data

Nursing Diagnosis

Risk for Ineffective Breathing (NANDA 1.5.1.3)

Student Goals

Student will demonstrate appropriate use of inhaler at the beginning of school year. Student will initiate treatment when symptoms appear throughout the school year.

Interventions

Airway Management (NIC 2K-3140)

Activities: Review use of inhaler with student at the beginning of the school year (Nurse).

Outcomes

Symptom Control Behavior (NOC 4Q-1608) Indicators: Recognizes symptom onset

Never Rarely Sometimes Often Consistently 1 2 3 4 5

12-year-old diagnosed asthma at age 9 Carries Proventil inhaler at all times

Characterized by shortness of breath, coughing, and/or wheezing related to asthma

At the beginning of the school year, review with teacher, and other appropriate staff, the signs and symptoms of asthma exacerbation and when student should use inhaler (Nurse). Every two months obtain student's record of inhaler use for documentation in health file. Report increased use of inhaler to parents/physician (Nurse). Emergency plan: See STUDENT ASTHMA ACTION CARD located in the classroom, locker room, and health office.

Uses preventive measures

Never

Rarely Sometimes Often Consistently

1

2 3 4 5

Independent in identifying symptoms and need for treatment M.D. order normal P.E. program

Student will keep record of peak flow meter readings if required throughout the school year. Student will keep record of use of inhaler for health office throughout the school year. Student will avoid having an emergency asthma attack during this school year.

Uses relief measures

Never

Rarely Sometimes Often Consistently

1

2 3 4 5

Reports controlling symptoms

Never

Rarely Sometimes Often Consistently

1

2 3 4 5

I have read and approve of the above plan for school healthcare: Parent signature Nurse signature Date reviewed by the educational team Physician signature (optional)

Adapted from: Arnold, M.J., & Silkworth, C.K. (1999). The school nurse's source book of individualized healthcare plans: Issues applications in school nursing practice Volume II and Zentner-Schoessler, S. (1997). Computerized version and manual Volume I. North Branch, MN: Sunrise River Press.

Page 6 of 8 Name: Address: Home Phone: Parent/Guardian: Day/Work Phone: Healthcare Provider: Provider's Phone: IHP Written by:

Iowa Individual Health Plan: Interpretive Statement

Example Individualized Healthcare Plan

Birthdate: School: Teacher/Counselor: Grade: IHP Date: IEP Date: Review Dates: ICD-9 Codes:

Assessment Data

Absent 36 school days this year (ND4) Hospitalized twice for migraines last school year Health office visits average 4-5 times/week Counselor office visits average 1-2 times/week Student's mother prefers herbals, biofeedback, and relaxation therapy be used before traditional medications Student's father prefers use of traditional medication therapy and does not believe alternative therapies are beneficial Three occasions this semester Naproxine supply was depleted; refills were not obtained until one week later

Nursing Diagnosis

Ineffective family management of therapeutic regimen related to inconsistent primary caregiver and multiple treatment strategies (NANDA 5.2.2)

Student Goals

The family will, in collaboration with their neurologist, develop a mutually agreeable migraine treatment plan.

Nursing Interventions

· Obtain a signed medical release for the health provider to release educationally relevant health records and for the school to share information with the provider. · Obtain medical orders for migraine management in the school setting. · Obtain parental & student consent to share relevant medical information with staff. · Identify parent's management expectations. · Assist to resolve conflict between family members in medication management. · Determine Student's level of dependence on caregivers. · Establish preferred scheduled communication with parents/grandparents/ health provider to facilitate coordination of treatment, monitor Student's medication/treatment tolerance, and monitor social-emotional adjustment. · Collaborate with the Family to set goals for school management. · Assist the family to adapt prescribed treatment into their lifestyle. · Assist family to focus on strengths and to advocate for Student · Encourage the family to set ageappropriate limits and expectation. · Collaborate with school counselor to locate community counseling services.

Expected Outcomes

Management of Student's migraines will be consistent across all settings.

Primary caregivers will comply with prescribed medial treatment.

Student will receive prescribed treatment for migraines in the school setting.

I have read and approve of the above plan for school healthcare: Parent signature Date reviewed by the educational team Nurse signature Physician signature (optional) Adapted from: Arnold, M.J., & Silkworth, C.K. (1999). The school nurse's source book of individualized healthcare plans: Issues applications in school nursing practice Volume II (pp. 233-234) and Zentner-Schoessler, S. (1997). Computerized version and manual Volume I. North Branch, MN: Sunrise River Press.

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Iowa Individual Health Plan: Interpretive Statement

Example Emergency Health Plan (EHP)

Student: Birthdate: Weight: Date: Parent(s): Home phone: Work phone numbers: Emergency phone numbers: Health Care Provider: Phone number: Preferred Hospital: Phone number: Preferred Ambulance: Phone number: Health insurance: Allergies: Usual Medications (dosage, time, route): Condition: Severe life-threatening allergic reaction to peanuts and peanut products Triggered by: Eating or contact with peanut products Signs of emergency: · Exposure to peanuts-proceed to actions 1,2, & 3 below immediately · Tightness of throat and or chest, difficulty breathing or talking · Generalized itching, rash, or hives · Swelling or eyes, lips, tongue, throat or neck · Blue or gray discoloration of lips or fingernails · Vomiting, stomach cramps or diarrhea · Seizures or loss of consciousness · Other Actions for school staff to take: 1. Administer Medication

Name EpiPen Jr Route Dose Frequency Location intramuscular injection* 0.15 mg Immediately Backpack & office medication cabinet

2. Request another adult phone 911 (ambulance) and inform of exposure and symptoms 3. Request another adult notify the school nurse, office, parents, physician

Remain calm and stay with student Monitor and maintain: A (airway) B (breathing) C (cardiac function) Provide CPR by a trained person as needed Send student health record with ambulance including: Allergen, signs and symptoms of distress, emergency measures instituted, response to emergency measures, time of all activities, including Epi Pen administration, signature of provider and phone number Accompany student to hospital if parents unavailable

4. If student is still at school in 15-20 minutes, repeat Epi Pen 5. Monitor blood pressure. Elevate legs if blood pressure is low 6. Cover with blankets if necessary to keep warm; don't allow blankets to interfere with handling or observation Other

*Directions for use of EpiPen 1. Pull off gray cap 2. Place black tip against upper outer thigh at right angle to leg 3. Press hard into outer thigh, until EpiPen clicks 4. Hold in place several seconds, then remove, massage injection area for 10 seconds 5. Discard in impermeable container per school policy, do not return to holder

Special Instructions (for health care provider to complete): Physician's Signature:

Parent Signature:

Date:

Date:

Emergency Provider(s) Notification:

Date:

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Iowa Individual Health Plan: Interpretive Statement

References

1. Arnold, M.J., & Silkworth, C.K. (Eds.). (1999). The school nurse's source book of individualized health care plans, Volume II. North Branch, MN: Sunrise River Press. 2. Bednarz, P.K. The Omaha system: A model for describing school nurse case management. Journal of School Nursing, 14, 24-30. 3. Brennan, C., & Clark, M. (1997). Computerized classroom health care plans for school nurses. Lake City, UT: JMJ Publishers. 4. Computerized care planning programs. [Online]. Available: http://www.schoolnurse.vservers.com/asnchot.htm. 5. Denehy, J., & Poulton, S. (1999). The use of standardized language in individualized healthcare plans. Journal of School Nursing, 15, 38-45. 6. Haas, M.B. (Ed.). Gerber, M.J.V., Kalb, K.M., Luehr, R.E., Miller, W.R., Silkworth, C.K., & Will, S.I.S. (1993). The school nurse's source book of individualized health care plans (Vol. 1). North Branch, MN: Sunrise River Press. ZentnerSchoessler, S. (Ed. of software and manual). (1997). Computerized Health Plans version and manual (Vol. 1). North Branch, MN: Sunrise River Press. 7. Hootman, J., & Carpenito, L. (1996). Nursing diagnosis: Application in the school setting. Scarborough, ME: National Association of School Nurses, Inc. 8. Iowa Administrative Code: Nursing practice §655--6 et seq. and Special health services §§281--41.96(2). (1998:1996). 9. Iowa Code: Nursing §152 et seq. and Education §§280.23. 10. Iowa Department of Education. (1998). Their future: Our guidance. Des Moines: State of Iowa. 11. Iowa Intervention Project, McCloskey, J.C., & Bulechek, G.M. (Eds.). (1996). Nursing intervention classification (NIC) (2nd ed.). St Louis: Mosby. 12. Iowa Outcomes Project. (1997). Nursing Outcomes Classification (NOC). St. Louis: Mosby. 13. National Association of School Nurses. (1997). Nursing assessment of school age youth. Scarborough, ME: NASN 14. National Association of School Nurses. (1998). Standards of professional school nursing practice. Scarborough, ME: NASN. 15 National Council of State Boards of Nursing. (1997). Delegation decision-making grid. DC: NCSBN. 16. North American Nursing Diagnosis Association. (1996). NANDA Nursing diagnoses: Definitions and classification 199798. St. Louis: NANDA. 17 Strawhacker, M. (1999). Individual student health plan: Risk for injury. Johnston, IA: Heartland Area Education Agency 11. 18. Wilkinson, J.M. (1991). Nursing process in action a critical thinking approach. Redwood City, CA: Addison-Wesley Nursing, A Division of the Benjamin/Cummings Publishing Company. 19. Zentner-Schoessler, S. (1997). The school nurse's source book of individualized health care plans (Vol. 1): Computerized health plans version and manual.

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