HCS School:
School Year:
School Hours:
Extracurricular Hours:
MANAGEMENT PLAN FOR PN
Individualized Healthcare Plan (IHP) / Emergency Action Plan (EAP) / Classroom Plan (CAP) / Extracurricular Plan
SECTION I – Parent (Please Print):
Student Name:
DOB:
Teacher/Grade:
Known Allergies/Triggers:
Medications Taken at Home:
Wt.
Emergency Contact:
Name
Cell #
Home #
Work #
Name
Cell #
Home #
Work #
Emergency Contact:
Physician:
Phone #:
Preferred Hospital in Case of Emergency:
Insurance Provider:
Policy/Group #
(optional)
(optional)
SECTION II – Physician: (Please Print)
Date of Central Venous Line (CVL) Placement
Type Central Catheter:
Single Lumen Broviac
Port-a-cath
Other
Central Venous Line (CVL) to be accessed, PN connected and disconnected at home by parent or home health
PN will run continuously throughout the school day and a battery powered pump will be worn by the student in a backpack.
Site to be secured with CVL Securement Vest:
YES
NO
Type of Formula:
Mixed per Pharmacy
EMERGENCY PLAN:

If his CVL were to break, the line should be immediately clamped above the break and his mother immediately notified so she
can transport him urgently to the hospital for repair. If student’s mother is unavailable call 911.

If the line were to become displaced/removed his mother should be notified immediately so he can be transported to the
hospital for urgent treatment. If student’s mother is unavailable call 911.

If the pump malfunctions or if PN is stopped abruptly student could become hypoglycemic. Contact student’s mother. If
student’s mother is unable to be contacted, he should be taken to the nearest hospital for placement of a peripheral IV and
D10W started until he is stable and can be safely transported to Children’s of Alabama for management of the CVL.

Diarrhea/fever/vomiting should be taken very seriously – these can be early signs of CVL infection. The student can become
quickly dehydrated. Student’s mother should be contacted and student sent home. If student’s mother is unavailable call 911.

Dietary restriction: avoid concentrated sweets
Student has a G-tube but does not require feedings during the school day.
Student should be allowed to participate fully in all classroom and outdoor activities without restrictions as physically able.
Student is aware of the need to protect his CVL and understands that his backpack must be worn at all times in order to
prevent inadvertent removal or injury to his line.
TRANSPORTATION PLAN: Parent will provide transportation.
*A School Physician/Parent Authorization (PPA) form must be completed for each medication to be administered during the school day.*
I UNDERSTAND AND AGREE WITH THIS MANAGEMENT PLAN:
I give permission for my child to be transported to the hospital indicated on this form, in the event of an emergency and for the release of my child’s
medical information to be shared with appropriate persons on an as-needed basis to insure the health and safety of my child. A nurse will not be
present on the school bus or private car.
Physician Signature
Date
Parent Signature
Date
Student Signature
Date
Nurse Signature
School Staff/Homeroom Signature
School Staff Signature
Date
Cafeteria Manager Signature
Date
Date
Sponsor/Coach Signature
Date
Date
Bus Driver Signature
Date
FOR SCHOOL NURSE USE ONLY
Medication
Self-Carry?
Self-Administer?
Revised 05/26/15
Expiration
Location of Medication
© Created by HCS