Diabetes Health Care Plan Template Page 4
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Student Name: ______________________________ DOB: ____________________ School: _____________________
School Nurse: ______________________
______ Date of IHP: _____________________
Nursing Diagnosis/Concern
Educational Goal
Plan of Action
By Whom/When
Potential for infection due to: high glucose lev-
Student will not develop infec-
Instruct student in good skin care techniques.
School Nurse
els providing medium for bacterial or fungal
tions and will self-treat (as able)
Diabetes educator
growth; depression of leukocyte function associ-
minor illnesses and injuries
Instruct students and parents in signs and symptoms of upper respira-
Physician
ated with high glucose levels; delayed healing due
appropriately
tory and urinary tract infections.
to fluid imbalance and high glucose; knowledge
A. Instruct students and parents in early treatment activities and
deficit related to prevention; knowledge deficit
need for physician evaluation.
related to early intervention.
Instruct students and parents in early treatment of skin injuries and
signsrequiring physician evaluation.
Student/family will
Parents/guardians will provide school nurse with a copy of current
Parent/guardian annually
Potential for change in medical status
collaborate with members of the
medical report or doctor’s statement annually or when a change in
health team to facilitate opti-
status occurs.
mum health and safety neces-
sary for learning
The school nurse will call the physician to obtain current information
School Nurse
verbally when necessary to enable management of the student’s condi-
tion at school.
Physician:
Phone:
The Individual Health Plan (IHP) will be reviewed annually with the
parent/guardian as well as appropriate to ensure the most current treat-
ment modalities for the student. The school nurse (in collaboration
with parent/guardian as well as appropriate staff members. This plan
may be revised/updated as appropriate to ensure the most current
treatment modalities for the student. The school nurse (in collabora-
tion with parent/guardian will train (or arrange for training) and
supervise all non-medically licensed school personnel who are dele-
gated responsibility for implementing any portion of this plan as ap-
propriate.
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