January, 2007
HAMDEN PUBLIC SCHOOLS
ALICE PECK SCHOOL
Hamden, Connecticut
INDIVIDUALIZED HEALTH CARE PLAN
Key to acronyms:
PDN = private duty nurse provided by family
AN = agency back up nurse provided by HPS
School Nurse = HPS school nurse responsible
for student health services at Alice Peck School
Student Name:
DOB: 1/9/01
PPT Date:
Dates of IHCP review:
ASSESSMENT
DATA
HEALTH
CONCERN
STUDENT
OBJECTIVE
INTERVENTIONS
July/August 2006
P. Schoen & N.
Schwab
Refer to individualized emergency care plan (IECP) for
specifics of managing ineffective respiratory function
See Health
Assessment
Summary dated:
___________
Altered respiratory
function related to
chronic lung disease
requiring
tracheostomy and
ventilator support.
IHCP edits from
PPT 11/17/06
N. Schwab
Risk for ineffective
respiratory function
and impaired gas
exchange related to:
chronic lung
disease; and
tracheostomy
(altered secretions plugging, ineffective
airway clearance)
Xxxxxx Yood (B.D. 1/9/01)
Xxxxxx will cooperate
100% of the time with
school-home nursing
staff, as able, in order
for nurses to:
 assess his
respiratory status
 provide routine and
emergency medical
treatments
 maintain a patent
airway
 maintain safe
oxygen blood levels
Xxxxxx will assist
with hand-over-hand
reattaching of trach to
Parents will:
1. Provide medical orders from Xxxxxx’s attending (current)
physicians for all specialized health care services requested in
school, including nursing interventions provided by the PDN,
AN and/or school nurse.
2. Apprise the principal (or principal’s designee) and school
nurse of any changes in Xxxxxx’s health status, including
changes in medications and treatments (for home or school),
and other relevant medical information.
3. Collaborate and communicate with Xxxxxx’s school team,
home care providers, and medical providers as needed to
facilitate Xxxxxx’s access to and safe participation in school.
4. Provide regular written communication on the daily report log
re Xxxxxx’s respiratory status since his last day in school.
5. Review Xxxxxx’s individualized health care plan (IHCP),
individualized emergency care plan (IECP), evacuation plan
and transportation plan with all PDNs who will accompany
Xxxxxx to school.
6. Provide a PDN to accompany Xxxxxx to school per contract
IHCP 2006-07
EVALUATION
.
Current medical
orders will be on
file in Xxxxxx’s
school health
records by the start
of school year with
updates as needed.
Documentation in
JY’s school health
record.
Documentation;
minutes of
meeting(s)
Daily report
documentation
Parent/PDN report
Signed contract
Page 1 of 10
January, 2007
ASSESSMENT
DATA
HEALTH
CONCERN
Risk of impaired
spontaneous
ventilation and
hypoxemia related
to respiratory
insufficiency
Risk of
dysfunctional
venilatory weaning
response related to:
fatigue; ineffective
airway clearance;
other physical/
emotional factor(s)
STUDENT
OBJECTIVE
INTERVENTIONS
ventilator and will
reattach 25% of the
time
7.
8.
Xxxxxx will learn two
consistent words to
identify symptoms of
increased respiratory
distress (changes from
his baseline) and use
them with accuracy 50
% of the time.
Risk for equipment
malfunction
Alteration in oral
motor function
related to medical
condition and lack
of use.
Xxxxxx Yood (B.D. 1/9/01)
Xxxxxx will have his
Passy Muir (speaking)
valve in 100% of the
time that he is in
school, so long as it is
not medically
necessary to remove it.
9.
EVALUATION
(herein called “PDN Contract”).
Provide and maintain medical equipment, oxygen,
medications, and supplies needed at school.
Contact the Town of Hamden Fire Department to work
through an agreement regarding EMS emergency services to
be provided to Xxxxxx in the event of an emergency (9-1-1
call) at school.
Keep Xxxxxx home when his medical condition prevents it or
the school environment puts him at undue risk of complication
(e.g., outbreak of influenza), as agreed with medical providers
and school team. See IEP re home program.
PDN will:
1. Accompany Xxxxxx to school and function as his primary
nursing care provider while at school and during
transportation.
2. On arrival to school, pick up a two-way radio from the health
office and, with the AN and school nurse, check
functioning/battery levels of all three radios each morning and
at least once more during the day.
3. Also on arrival to school, check on oxygen supply, trach bag,
and functioning of oxygen, ventilator, suction unit, and other
equipment and supplies; complete daily check list and report
any concerns to school nurse.
4. Make sure that Xxxxxx has with him at all times: his trach
bag, two (2) ambu bags, compressed oxygen, and suction
equipment.
5. Follow the medical orders and nursing care plan for Xxxxxx
for his respiratory and tracheostomy care, as agreed with
Xxxxxx’s physicians, the PDN’s agency and parents, and
within the parameters of Xxxxxx’s individualized education
program, IHCP and nursing judgment.
6. Communicate and collaborate with Xxxxxx’s teacher, other
classroom staff, AN, and school nurse in order to support and
enhance Xxxxxx’s safety, learning, and independence in the
classroom and other educational settings, including supporting
IHCP 2006-07
Documentation of
plan
Documentation in
Xxxxxx’s school
records.
Checklist &
documentation
Daily checklist
documentation
Documentation of
agency nursing
care plan in school
health record
Documentation in
school records
Page 2 of 10
January, 2007
ASSESSMENT
DATA
HEALTH
CONCERN
Alteration in
mobility related to
disuse of legs (long
hospitalizations,
medical condition)
STUDENT
OBJECTIVE
INTERVENTIONS
Xxxxxx will ambulate
(walk by himself)
100% of the time that
he is in school, except
when he is medically
unable to do so.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
Xxxxxx Yood (B.D. 1/9/01)
IHCP 2006-07
EVALUATION
Xxxxxx in using his speaking valve and in walking by himself
at all times that it is not medically necessary to do otherwise.
Attend to and provide Xxxxxx’s medical care in a way which
is least disruptive to the education and learning of Xxxxxx and
other students in the classroom.
Use proper infection control techniques, including hand
washing, and protective equipment, as required by OSHA.
Monitor oxygen levels and heart rate to indicate possible
problems and assess Xxxxxx, as needed, related to symptoms
of respiratory effort/distress, work of breathing, skin color
changes, agitation, etc.
Decide when it is necessary for Xxxxxx to rest, employ his
ventilator, use/increase oxygen, etc., and when it may be best
to remove him from the classroom for care. See also IECP.
Regularly check for and trouble shoot ventilator malfunction.
Immediately radio the AN and school nurse for help if Xxxxxx
shows signs of an impending or actual emergency (see IECP).
Implement the emergency care plan and direct other nurses in
assisting with emergency interventions except as otherwise
specified in the PDN Contract.
Bring all of Xxxxxx’s life-saving equipment, medications and
supplies when it is necessary to exit the building for any
reason, including fire drills; use assistance of paraprofessional
or AN as appropriate (see evacuation plan).
Maintain the privacy of Xxxxxx’s family and of other students
at all times.
Using the daily record log, communicate with Xxxxxx’s
parents about his daily health status and care in school,
including health-related interruptions to his educational
program (non-routine).
Allow Xxxxxx’s teacher and other school staff to be the
school-home communicators regarding Xxxxxx’s educational
program and progress, classroom events, and related issues, as
these are appropriately the purview and expertise of
educational staff.
[more of this
section will need
filling in by school
nurse; most of
evaluation will be
by observation and
documentation…]
Documentation on
daily log; record of
other
communications.
Page 3 of 10
January, 2007
ASSESSMENT
DATA
HEALTH
CONCERN
Xxxxxx Yood (B.D. 1/9/01)
STUDENT
OBJECTIVE
INTERVENTIONS
EVALUATION
AN will:
1. Be competent to assist with or, if necessary, take over
management of Xxxxxx’s health care during school, including
routine and emergency interventions.
2. Be immediately available by radio communication in the
general vicinity of Xxxxxx’s classroom in order to respond
immediately (approximately 30 seconds) to a summons for
help by the PDN or classroom teacher. [For orientation
purposes, AN will initially need to be in the classroom to
perform hands-on care and learn Xxxxxx-specific nursing
strategies. Once competent, AN will be in the classroom only
periodically, but will always be in the general vicinity of the
classroom and readily available by two-way radio].
3. Assist the PDN in emergency interventions, following the
emergency care plan, except as otherwise specified in the PDN
contract.
4. Assist the PDN in an evacuation, if indicated according to the
evacuation plan.
5. Monitor Xxxxxx in the classroom when the PDN needs to
leave briefly for personal reasons.
6. Be responsible for Xxxxxx’s routine and emergency care in
the event that the PDN suddenly becomes incapacitated during
the school day.
7. Use proper infection control techniques, including hand
washing, and protective equipment, as required by OSHA.
8. Communicate and collaborate with Xxxxxx’s teacher, other
classroom staff, PDN and school nurse in order to support and
enhance Xxxxxx’s safety, learning, and independence in the
classroom and other educational settings.
9. Be familiar with trouble shooting ventilator and other
equipment malfunctions.
10. Make recommendations to the school nurse regarding changes
and enhancements to Xxxxxx’s IHCP or IECP.
11. Maintain confidentiality of Xxxxxx and other students at all
times.
Review and specify
“general vicinity”
after practice runs
from adjacent and
nearby rooms by
September 7th.
Review orientation
of AN and
readiness to move
outside classroom
after two weeks (by
September 20,
2006).
IHCP 2006-07
Page 4 of 10
January, 2007
ASSESSMENT
DATA
HEALTH
CONCERN
STUDENT
OBJECTIVE
INTERVENTIONS
EVALUATION
School nurse will:
1. Review and revise the IHCP, IECP, ITP and evacuation plans,
in collaboration with the school team, parents and Xxxxxx’s
health care providers, as indicated by Xxxxxx’s health status,
medical orders, and educational progress.
2. Review all new or revised medical orders and nursing
protocols with the authorizing prescriber, parents, and PDN, as
needed, for appropriateness in school before incorporating
them into the IHCP, IECP, ITP or evacuation plan; advise
school team members accordingly.
3. Review pertinent aspects of Xxxxxx’s IHCP, IECP, ITP and
evacuation plans, as well as infection control requirements,
techniques and supplies/equipment with school team members
who work with and have responsibility for Xxxxxx.
4. Interpret for other members of the school team information
about Xxxxxx’s health status, routine and emergency medical
care needs, and their implications for school attendance and
learning.
5. Communicate daily with the PDN, AN, classroom teacher and,
as needed, with Xxxxxx’s parents regarding Xxxxxx’s current
health status and school health issues or needs.
6. Monitor the nursing care provided for Xxxxxx in school,
including quality and consistency based on the IHCP, IECP,
IEP, PDN contract, and nursing standards of care. Notify the
preschool administrator of any concerns.
7. Collaborate with the preschool administrator in supervising
and directing the AN.
8. Be prepared and competent (through professional development
and practice/training) to assist with and, if necessary, take over
management of Xxxxxx’s health care during school, including
routine care and emergency interventions.
9. Ensure availability of protective equipment for all staff
providing direct care to Xxxxxx, as required by OSHA, and
use proper infection control techniques, including hand
washing and protective equipment in providing direct care.
Xxxxxx Yood (B.D. 1/9/01)
IHCP 2006-07
Page 5 of 10
January, 2007
ASSESSMENT
DATA
HEALTH
CONCERN
STUDENT
OBJECTIVE
INTERVENTIONS
EVALUATION
10. Be available in the building by two-way radio communication
at all times in order to respond as rapidly as possible to a
summons for help by the PDN, AN or classroom teacher. [For
purposes of becoming competent in Xxxxxx’s care, the school
nurse will require time in the classroom to perform hands-on
care and learn Xxxxxx-specific nursing strategies. This will
be accomplished at different times than when the AN is so
oriented in order to keep the number of nursing staff in the
room at a minimum. Once competent, the school nurse will be
in the classroom as needed to fulfill her regular
responsibilities].
11. In the absence of the AN, or if needed in addition, assist the
PDN in emergencies, following the emergency care plan,
except as otherwise specified in the PDN contract. Except as
prevented by the urgent or emergent needs of other students,
the school nurse will attend every emergency tracheostomy
care rendered while Xxxxxx is at school (see EHCP).
12. Assure that a daily report by PDN or AN is provided to
Xxxxxx’s parents to communicate his respiratory status and
ability to participate in school/classroom activities while at
school (See daily report log).
13. Be familiar with trouble shooting ventilator and other
equipment malfunctions.
14. Participate in IEP team meetings for Xxxxxx, update his health
assessment history as needed, and propose changes to
Xxxxxx’s IHCP, IECP, ITP, evacuation plan and IEP, as
appropriate.
15. Notify the program administrator immediately if Xxxxxx will
be out of school for medical reasons (due to his own health
status or school environment). Assist with transition to
homebound services when indicated.
Daily log entries
will provide data
regarding time on
ventilator, time
without Passy Muir
valve and inability
to ambulate
himself (nonroutine).
Documentation of
homebound
services when
appropriate to
implement.
Teacher will:
1. Consult and collaborate with the school nurse, and as needed
with the PDN and AN, about Xxxxxx’s health status and
Xxxxxx Yood (B.D. 1/9/01)
IHCP 2006-07
Page 6 of 10
January, 2007
ASSESSMENT
DATA
HEALTH
CONCERN
STUDENT
OBJECTIVE
INTERVENTIONS
2.
3.
4.
5.
6.
Alteration in
nutrition related to
medical condition
with delayed oralmotor development,
feeding via
gastrostomy tube,
decreased oral
stimulation, and
oral aversion.
.
Xxxxxx Yood (B.D. 1/9/01)
Xxxxxx will cooperate
with nursing staff to
allow the delivery of
nutrients and liquids by
G-tube during school
as required, 100% of
the time.
1.
2.
EVALUATION
health care needs in school in advance of Xxxxxx’s first day of
school and thereafter on a daily basis.
Use and require all classroom personnel to use appropriate
hand washing and infection control techniques.
Direct Xxxxxx’s educational program and daily activities in
the classroom, including aspects related to activities of daily
living, and direct all staff ,including the PDN and AN,
regarding classroom rules, procedures, routine and
expectations.
Notify the parents and school nurse of upcoming classroom,
curricular and extracurricular events that have implications for
Xxxxxx and/or may require advance planning.
Collaborate with the school nurse, other nurses, parents and
other school team members, as appropriate, to evaluate the
possibility of and plan in advance for Xxxxxx’s participation
in special programs, field trips, etc.
Apprise the preschool administrator and school nurse of the
impact of Xxxxxx’s medical care in the classroom and
collaborate with them in finding solutions to problems that
may arise. Parents will be included in joint problem solving
whenever appropriate.
Xxxxxx’s private duty nurse will administer Pediasure and water
via his G-tube during the school day as ordered by his doctor, and
will make sure that Xxxxxx remains properly satiated and
hydrated throughout the school day.
All nurses feeding Xxxxxx will follow the IEP feeding protocol as
provided by Laurie Overland.
MD orders; IEP
goals and
objectives; ongoing nursing,
teacher and
therapist
documentation
Xxxxxx will cooperate
in following the
feeding-skill
development program
100% of the time.
IHCP 2006-07
Page 7 of 10
January, 2007
ASSESSMENT
DATA
HEALTH
CONCERN
STUDENT
OBJECTIVE
INTERVENTIONS
EVALUATION
Xxxxxx will interact
with one or more peers
during lunch in the
cafeteria 75% of the
time.
HELP NEEDED
HERE
Alteration in
elimination
Xxxxxx will
participate in his toilet
training by ??? [what,
indicating a need? -parents will need to
help here in terms of
where he is at] 75 %
of the time.
The PDN will:
1. Assist Xxxxxx to use the toilet in school, consistent with his
toileting at home, as appropriate based on his IEP goals and
objectives, and classroom rules and routine.
2. Make sure that Xxxxxx stays clean and dry during the school
day, and change Xxxxxx’s diaper, as needed, unless otherwise
indicated in Xxxxxx’s IEP.
The teacher will:
 direct Xxxxxx to use the toilet according to classroom
procedures and Xxxxxx’s IEP objectives.
Fatigue related to
medical condition
and related
compromised
endurance.
Xxxxxx will
communicate the need
to rest by using one
consistent phrase and
alerting an adult, 75%
of the time.
The school nurse will:
1. Collaborate with the PDN, AN and teacher to develop a visual
prompt to use in teaching Xxxxxx to identify, and then to
consistently verbalize, symptoms of fatigue. [for example, a
pain rating scale can be adapted to use for a fatigue rating
scale]
2. Review with staff the importance of encouraging Xxxxxx to
be as independent as possible, even when he experiences
some fatigue, and help staff to distinguish between normal
fatigue and fatigue related to respiratory compromise.
Xxxxxx will cooperate
with teachers and
nurses by resting when
directed to do so (due
to observable signs and
symptoms), 100% of
the time.
Xxxxxx Yood (B.D. 1/9/01)
The PDN will
1. Determine if Xxxxxx should continue, alter or stop his
participation in classroom/learning activities when he is
IHCP 2006-07
Documentation on
the daily log.
Page 8 of 10
January, 2007
ASSESSMENT
DATA
HEALTH
CONCERN
STUDENT
OBJECTIVE
INTERVENTIONS
2.
3.
EVALUATION
demonstrating signs and symptoms of fatigue.
Consult with the school nurse and teacher about her
observations of Xxxxxx’s fatigue and potential relationships to
classroom/educational activities. Include this information on
the daily log.
Assist Xxxxxx with therapy and educational programs at
school as directed by the classroom teacher and agreed to in
the PDN contract.
The teacher will :
1. Collaborate with nursing personnel to assess Xxxxxx’s fatigue
related to his educational program and recommend/implement
changes to his classroom routine accordingly.
2. Regularly communicate with Xxxxxx’s parents regarding
Xxxxxx’s fatigue and related health issues as they appear to
impact his learning and participation in the classroom.
3. Collaborate with the school nurse, PDN, and AN to develop a
visual prompt to use in teaching Xxxxxx to identify, and then
to consistently verbalize, symptoms of fatigue
4. Incorporate into Xxxxxx’s educational routine use of a fatigue
scale or other prompt to assist Xxxxxx in recognizing and
verbalizing symptoms of fatigue.
Other:
See also the Daily Report and Checklist forms
School Nurse:______________________________________ Date________
Xxxxxx Yood (B.D. 1/9/01)
IHCP 2006-07
Page 9 of 10
January, 2007
Review by: Parent __________________________________ Date________; Student____________N/A______________Date_________
Xxxxxx Yood (B.D. 1/9/01)
IHCP 2006-07
Page 10 of 10