Nursing Care Plan Allergies

INDIVIDUALIZED HEALTHCARE PLAN – 5-2-1-0 Healthy Lifestyle Date Initiated:

Student’s Name: DOB: School: Grade:

ESE: Yes No MEDICAL DIAGNOSIS: Healthcare Provider: Parent/Guardian Name: RN Name Medications: Allergies NURSING DX PLAN AND GOALS INTERVENTIONS EVALUATION/OUTCOME DATE INITIAL Nutrition: More Student will Speak with parent/guardian decrease/maintain (elementary/middle) or student with parent than Body weight with good permission (middle/high school) Requirements, health habits.  Deliver 5-2-1-0 message Imbalanced  Ask parent/student if they would like to work on a 5-2-1-0 Goal

If "yes"...  Use Healthy Weight Survey for School Nurses to gather information about lifestyle habits.  Assess potential barriers to progress and readiness for change.  Make recommendation for a 5-2-1-0 Goal.  Send 5210 Resource Packet home to student/family. This may include: (1).5- 2-1-0 Booklet (2).5-2-1-0 Tracking Form (Return to School Nurse recommended but not required) (3).5- 2-1-0 Magnet (4).Other handouts as determined by the School Nurse.

If "no"...  Or if unable to talk with parent/guardian after three attempts, then categorize student as Incomplete.

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Student’s Name: DOB: School: Grade: NURSING DX PLAN AND GOALS INTERVENTIONS EVALUATION/OUTCOME DATE INITIAL Student will improve Nutrition Nutrition his/her outcome Weight Loss Behavior (NOC rating from ____ to Goal 5- Eat at least 5 servings of 1627) ____ by the end of fruits and vegetables on most days the school year. If at Obtains information on level 5, will maintain Discuss/teach how to incorporate 5 nutrition and physical activity, this outcome rating. servings of fruits and vegetables on weight loss strategies, from most days using 5-2-1-0 Healthy health professional (NOC Lifestyle Goal Worksheet and Make 162701) 5-2-1-0 Your Goal Every Day booklet. 1- Never demonstrated 2- Rarely demonstrated Goal 0-No soda, sugar sweetened 3- Sometimes demonstrated drinks and whole milk 4- Often demonstrated 5- Consistently demonstrated Discuss/teach how to delete soda, Selects nutritious food and sugar sweetened drinks and whole milk fluid (NOC 162704) from diet using 5-2-1-0 Health 1- Never demonstrated Lifestyle Goal Worksheet and Make 2- Rarely demonstrated 5-2-1-0 Your Goal Every Day booklet. 3- Sometimes demonstrated 4- Often demonstrated Nutritional Counseling (NIC 5246) 5- Consistently demonstrated  Determine student's eating habits. Food likes and dislikes. Identify Plans for situations that affect food stimuli and eating food and fluid intake (NOC environment. 162711) 1- Never demonstrated  Determine student's/parent's 2- Rarely demonstrated knowledge of Choose My Plate 3- Sometimes demonstrated and basic food groups. 4- Often demonstrated 5- Consistently demonstrated  Review school menu. Discuss healthy food choices in school Uses diary/tracking form to cafeteria. monitor food and fluid intake (NOC 162724)  Teach how to maintain food 1- Never demonstrated diary/tracking form. 2- Rarely demonstrated 3- Sometimes demonstrated 4- Often demonstrated  Teach caloric value/energy 5- Consistently demonstrated expenditure relationship. D:\Docs\2017-12-14\0cfb38fd5251ae77dc37a5643eb5e97a.doc Page 2 of 4 INDIVIDUALIZED HEALTHCARE PLAN – 5-2-1-0 Healthy Lifestyle Date Initiated:

Student’s Name: DOB: School: Grade: NURSING DX PLAN AND GOALS INTERVENTIONS EVALUATION/OUTCOME DATE INITIAL Student will improve Physical Activity Physical Activity his/her outcome rating from ____ to Goal 2- Reduce screen time to 2 Establishes an exercise ____ by the end of hours or less every day routine (NOC 162706) the school year. If at 1- Never demonstrated level 5, will maintain Discuss/teach ways to decrease screen 2- Rarely demonstrated this outcome rating. time to 2 hours or less every day using 3- Sometimes demonstrated the Healthy Lifestyle Goal Worksheet 4- Often demonstrated and Make 5-2-1-0 Your Goal Every 5- Consistently demonstrated Day booklet.

Goal 1- Participate in at least 1 hour Uses diary/tracking form to or more of physical activity every monitor exercise (NOC 162725) day 1- Never demonstrated 2- Rarely demonstrated Discuss/teach ways to incorporate at 3- Sometimes demonstrated least 1 hour or more of physical activity 4- Often demonstrated every day using the Healthy Lifestyle 5 - Consistently demonstrated Goal Worksheet and Make 5-2-1-0 Your Goal Every Day booklet. Uses diary/tracking form to monitor screen time Exercise Promotion (NIC 0200) 1- Never demonstrated  Explore student's prior 2- Rarely demonstrated exercise /physical activity 3-Sometimes demonstrated experiences 4- Often demonstrated 5- Consistently demonstrated  Explore barriers to physical activity

 Help student to schedule regular times for physical activity in weekly routine.

 Monitor adherence to physical activity plan

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Student’s Name: DOB: School: Grade:

NURSING DX PLAN AND GOALS INTERVENTIONS EVALUATION/OUTCOME DATE INITIAL Student's BMI will be Weight Management (NIC 1260) Weight Management in healthy range.  Weigh student with parental Monitors body weight (NOC Student will improve permission. Frequency to be 162722) his/her outcome determined by parent and 1- Never demonstrated rating from ____ to 2- Rarely demonstrated School Nurse ____ by the end of 3- Sometimes demonstrated the school year. If at 4- Often demonstrated If 5-2-1-0 Goal(s) achieved... level 5, will maintain 5- Consistently demonstrated  Ask about interest in pursuing this outcome rating. another 5-2-1-0 Goal Monitors body mass index (NOC 162723)  Provide student with 5-2-1-0 1- Never demonstrated Certificate 2- Rarely demonstrated 3- Sometimes demonstrated If 5-2-1-0 Goal(s) not achieved... 4- Often demonstrated  Continue supporting 5-2-1-0 5- Consistently demonstrated Goal with resources and encouragement. Maintains progress toward target weight ( NOC 162726) 1- Never demonstrated 2- Rarely demonstrated 3- Sometimes demonstrated 4- Often demonstrated 5- Consistently demonstrated

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