<p> Diabetes Individualized Healthcare Plan (IHCP)</p><p>Student: ______Date of Birth: ______Grade: ______Teacher/Staff Contact Person: ______</p><p>Student’s Secondary Health Concerns (if applicable): ______</p><p>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.</p><p>School Nurse’s Name: ______Nurse’s Signature: ______Date of IHCP: ______</p><p>Revised November 2013 Diabetes Individualized Healthcare Plan (IHCP) Student Name: ______</p><p>_ Student Health Status (2005) _</p><p>_ a. Physical health (200501) _</p><p>_ b. Mental health (200502) _</p><p>_ c. School attendance (200503) _</p><p>_ d. Readiness to learn (200504) _</p><p>_ e. Return to class after visit to health office (200508)</p><p>) l f. Reports to the health office for medications at appropriate time a i t i (200511) n I</p><p>& g. Participation in self-care activities (200514)</p><p> e t h. Students with chronic illness or special needs managed according to a D</p><p>( IHCP/IEP (200515)</p><p> d i. Participation in physical activities (200519) e t</p><p> n j. Healthy dietary habits (200523) e Severely Not m Substantially Moderately Mildly</p><p> e Compromised Compromised l</p><p> p 1 2 3 4 5 N/A Indicator</p><p> m (Date) (Date) (Date) (Date) (Date) (Date) I a. b. c. d. e. f. g. h. i. j.</p><p>School Nurse’s Name: ______Nurse’s Signature: ______Date of IHCP: ______</p><p>Revised November 2013</p>