Diabetes Individualized Healthcare Plan (IHCP) Student Name: ______

Diabetes Individualized Healthcare Plan (IHCP)

Student: ______Date of Birth: ______Grade: ______Teacher/Staff Contact Person: ______

Student’s Secondary Health Concerns (if applicable): ______

Nursing Diagnoses: Knowledge deficit related to disease management and prescribed treatment regimen (NANDA 00126) Risk for Unstable Glucose (NANDA 00179) Student Goal(s): Student will demonstrate understanding of the disease process and management. Student will maintain normal blood glucose.

School Nurse’s Name: ______Nurse’s Signature: ______Date of IHCP: ______

Revised November 2013 Diabetes Individualized Healthcare Plan (IHCP) Student Name: ______

_ Student Health Status (2005) _

_ a. Physical health (200501) _

_ b. Mental health (200502) _

_ c. School attendance (200503) _

_ d. Readiness to learn (200504) _

_ e. Return to class after visit to health office (200508)

) l f. Reports to the health office for medications at appropriate time a i t i (200511) n I

& g. Participation in self-care activities (200514)

e t h. Students with chronic illness or special needs managed according to a D

( IHCP/IEP (200515)

d i. Participation in physical activities (200519) e t

n j. Healthy dietary habits (200523) e Severely Not m Substantially Moderately Mildly

e Compromised Compromised l

p 1 2 3 4 5 N/A Indicator

m (Date) (Date) (Date) (Date) (Date) (Date) I a. b. c. d. e. f. g. h. i. j.

School Nurse’s Name: ______Nurse’s Signature: ______Date of IHCP: ______

Revised November 2013