HEALTH CARE PLAN PROCESS
IDENTIFICATION
How are students with health care needs identified in your school? ((link) Ð
NOTIFICATION
How and when does the school notify the nurse of these students? (link) Ð
DEVELOPMENT OF HEALTH CARE PLAN Does every student need a HCP and how do I create one?
Ð
RN Assessment of Health Condition Ð
Assessment Tools/Questionnaires Ð
Creating the Health Care Plan
Ó Ð Ô
Approved Standardized Health Care Plan Template
(link)
Special Condition’s Health Care Plans
(link)
Health Care Plan Resources (link)
Sample Health Care Plans
Ð
REVIEW AND MODIFY HEALTH CARE PLAN Will I need to make changes to the HCP?
Ð
SIGNATURES
Who needs to sign the finalized Health Care Plan?
Ó Ð Ð Ô
RN Parent/guardian Health Care Provider Others
Ð
Implementing the Health Care Plan What do I do next, now that I have a written plan?
Ó Ð Ô
Distribution of Health Care
Plan Staff/ Student Training Delegation of Nursing Tasks
Ð
EVALUATION Is this plan working?
DEVELOPING AND USING INDIVIDUALIZED HEALTH CARE PLANS
The individualized health care plan (HCP) communicates nursing care needs to regular and special education educators, administrators, teachers, health assistants and parents. The HCP is written by the professional school nurse (RN) for students with a health condition that require the performance of a specific treatment, such as non-routine medication treatment, health treatment, emergency action or invasive health procedure. The Health Care Plan helps to ensure that all necessary information, needs, and plans are considered to maximize the student’s participation and performance in school.
The students do not need to be classified as special education or having a 504 plan in order to benefit from an individualized health care plan. Not all students in special education or those with a 504 plan necessarily need a HCP.
(FLOW CHART)
IDENTIFICATION of students needing Health Care Plan
How will you find out if a student in your school has a significant health problem that you need to be aware of and will need a HCP? Health Information may be obtained from various sources. The following are examples that your district may already be using or you may want to consider.
• Emergency forms – Your district emergency form should include: name of health care provider with contact information, release for emergency care, statement of current health needs, current medications and health insurance information. This form should be
completed by the parent or guardian on an annual basis and with any changes during the school year.
• Health Inventory – It is recommended that the school obtain a more complete health inventory for each student on an annual basis. This information should be collected and kept in a confidential manner. This information will help you decide what health accommodations may be necessary in the school setting. (link to sample)
• Teacher/Parent/Student/Health Care Provider referrals – At the beginning of each year communicate with staff, family and community providers the model of school health services in your school and the referral process to the school nurse.
• Medication forms – Refer to “notification form” medication section (link)
• IEP/504/Student Study Team – Identify the discipline that collects the health information for the initial special education assessment and triennials. Educate your special education team members on the referral process to the school nurse regarding children with
identified health needs.
• Child Find – Identify the discipline that collects the health information for the initial assessment and triennials. Educate your special education team members on the referral process to the school nurse regarding children with identified health needs.
• Transition or re-entry – If a child is hospitalized or absent for an extended period of time, make sure that emergency information and current health needs are updated.
NOTIFICATION OF SCHOOL NURSE
Key school personnel that may be involved at point of school entry for a student (eg. registration, SPED, child find) should be educated regarding when to contact the school nurse for students with significant health concerns. Entry may be delayed for students requiring specialized
procedures or emergency care until a HCP has been developed with the parent/guardian and health care provider. What key health conditions require school nurse notification? (link)
DEVELOPMENT OF HEALTH CARE PLAN
A HCP helps to ensure that all necessary information, needs and plans are considered to maximize the student’s participation and performance in school. The registered school nurse establishes the type, amount and intensity of nursing care required by a particular student in collaboration with the family, school, and healthcare provider. The HCP also covers other aspects of care such as a student’s knowledge about their condition, self care abilities and any modifications needed to enhance learning and prevent emergencies
RN Assessment of Health Conditions
The first step should be an assessment of health needs that may indicate the need to develop a Health Care Plan. The following is a brief checklist to determine if a HCP is needed.
Do Health Problems Require: Yes No
• Special training of school personnel ___ ___
• Modification in school environment ___ ___
• Added safety measures ___ ___
• Measures to relieve pain ___ ___
• Self-care assistance ___ ___
• Rehabilitation measures ___ ___
• Treatments orders for special procedures ___ ___
• Special diet ___ ___
• Medications or interventions for
emergency treatment ___ ___
Assessment Tools and Questionnaires: Questionnaires or assessment forms are available to help in developing the HCP. These forms can be given to the parent to complete or used by the school nurse during the parent interview. The information obtained will be used to complete the HCP.
• Nurse Consultant Assessment and Checklist for Children with Special Needs (CDE) • Planning Checklist for IEP/HCP Development (CDE)
• Diabetes Intake Form (link)
• Severe Allergy Intake Form (CDE form) • Seizures Questionnaire (link)
• Asthma Questionnaire (link)
• NASN samples (Tics/Tourettes, Headache) Creating the Heath Care Plan
The following Health Care Plans are the more frequently needed plans and available for use in your school. Remember that this plan will be used by non-medical staff members and should be easy to read and easily understood.
• Approved Standardized Plans (separate links) Asthma
Diabetes
Severe Allergy (Children’s) Seizures (Epilepsy Foundation)
• Health Care Plan Template – This is a basic form that can be individualized for various health conditions (link to sample form)
Health Care Plan Resources
The following publications have a wide range of Health Care Plans that may be adapted for use.
Computerized Classroom Health Care Plans for School Nurses, 1997
JMJ Publishers
1156 Wilson Ave
Salt Lake City, Utah 84105 (801) 487-3017 (available on disc)
Individualized Healthcare Plans for the School Nurse, 2005 Sunrise River Press
11481 Kost Dam Rd North Branch, MN 55056
(612) 583-3239 (available on CD) www.schoolnursebooks.com
Quality Nursing Interventions in the School Setting, 2004 NASN
P.O. Box 1300
Scarborough, ME 04070 (877) 627-6476
www.NASN.org Disease Specific Resources
Asthma: www.schoolasthmaallergy.com/2002-2003/sections/toolkit/library/ActionPlan.pdf http://www.alacolo.org/pdf/ALAEnglish/Health%20Care%20Plan.pdf
National Jewish Asthma & Allergy Center (web site)
Diabetes: www.cde.state.co.us/cdesped/download/pdf/nur-IHP.pdf
Pink Panther Diabetes Book Barbara Davis Center for Diabetes (Available on line and for purchase)
Pediatric Education for Diabetes in Schools www.pedsonline.org
Helping the Student with Diabetes Succeed
Complete online version available at www.ndep.nih.gov.
Seizures: www.epilepsyfoundation.org/programs/schoolnursewww.epilepsyfoundation.org
Procedure Manuals
Children and Youth Assisted by Medical Technology in Educational Settings, Stephanie Porter, et al.
Paul H Brookes Publishing Company P.O. Box 10624
Baltimore, MD 21285
Quality Nursing Interventions in the School Setting NASN
P.O. Box 1300
Scarborough, ME 04070 (877) 627-6476
www.NASN.org
REVIEW AND MODIFY HEALTH CARE PLAN
After reviewing the initial Health Care Plan with parent/guardian, school personnel, student, or health care provider, you may find that changes are necessary. The draft Health Care Plan may be available in the interim to key school personnel until the plan is finalized.
SIGNATURES
The school nurse should sign and date all Health Care Plans. Parent/guardian signature should be obtained for all plans that include medications, treatments or procedures that need to be performed during the school day. The signature of the Health Care Provider with prescriptive authority is required on all plans with medications, treatment or special procedure orders. Note: if Health Care Provider’s signature is documented elsewhere (eg medication form, written authorization), additional signature of Health Care Provider on the health care plan is not needed. Other signatures that may need to be included are students and/or administrators. Districts should establish procedures that clarify what signatures are required.
IMPLEMENTING THE HEALTH CARE PLAN
Distribution of Health Care Plan
Health Care Plans contain confidential information and by law may only be shared only with individuals in the school setting who have a specific and legitimate educational interest in the
information. Health information in the educational setting is regulated under FERPA (Federal Educational Records Privacy Act). Individuals who may need access to the plan include the classroom teacher, team leader, office staff, bus drivers, specials teachers, support services, special education staff, paraprofessionals, recess aides, cafeteria staff, and administrative staff. Advise the classroom teacher to keep a copy of the plan in a confidential folder for substitute teachers. Other copies should be kept in the student’s health folder and in a central location (eg. health room or front office) easily accessed by staff for emergencies. Emailing of plans is discouraged due to security issues. A list of staff who have received the Health Care Plans should be maintained.
Staff/Student Training
The school nurse in consultation with the student’s parents and health care providers, should use information from a thorough health assessment to determine the following:
• Level of care needed • Equipment needed
• Personnel qualified to provide for the student’s health care needs • Modifications or accommodations
Topics of training should include: • Confidentiality
• Overview of student’s health condition
• Review of health concerns/emergencies and action(s) to be taken as outlined in the health care plan
• Student specific health care procedures may also include delegation to designated personnel who demonstrate competency to the RN. (see delegation section)
• Roles and responsibilities of school personnel including transportation and emergency planning
Training should be provided and updated on an annual basis and when the student’s health condition or equipment changes. Training should be documented.
Delegation of Nursing Tasks
“Delegation is the transfer of responsibility for the performance of an activity from one individual to another while retaining accountability for the outcome.” (ANA 1992)
Nursing tasks and procedures may be delegated by the supervising school registered nurse based upon nursing judgment, however the professional nursing judgment of assessment, evaluation, and care planning may not be delegated to unlicensed school personnel.
The delegating RN determines whether a nursing task or procedure can be properly and safely performed by unlicensed school personnel. A nursing task or procedure can be delegated by the school registered nurse provided the unlicensed school personnel has demonstrated competency to perform the task through the training process.
A schedule for periodic evaluation of continuing competency of unlicensed school personnel should be established by the RN. The delegating nurse should determine the frequency of evaluation. Refer to the CDE: The School Nurse and Delegation.
• Colorado Nurse Practice Act – Delegation Clause (Chapter 13 – link)
• Criteria for Determination of Delegation to Unlicensed Personnel in the School Setting (link) jeffco
• Procedures Requiring Delegation and/or Training to Unlicensed School Personnel (link) needs to be reviewed by Judy / BON***
• Individualized Procedures and Checklist
Children and Youth Assisted by Medical Technology in the Educational Setting (link) is a good reference book that contains various procedures and checklists for skill
demonstration to help you document delegation and review of competency.
EVALUATION
School nurse should review and update the Health Care Plan annually and when changes occur in the health status of the student. The Health Care Plan is not a onetime event but rather is a dynamic document that should be evaluated periodically. Evaluation process includes reviewing the desired student goals and outcomes and determining the appropriateness and effectiveness of the Health Care Plan in the school environment. Care coordination should include periodic assessment and documentation of student response to Health Care Plan and/or treatments.
STUDENT HEALTH INFORMATION
School Year :
STUDENT NAME: __ Birthdate: Grade: School:
HEALTH CONCERNS YES NO MEDICATION
(Name, dosage) NECESSARY MONITORING IN SCHOOL COMMENTS OR DESCRIBE ASTHMA/ RESPIRATORY SEVERE ALLERGIES FOOD LATEX INSECTS NUTS type of reaction date of last reaction:
DIABETES Equipment:
HEAD INJURY SEIZURES/ NEUROLOGICAL/ MIGRAINES
Type & date of last episode
HEART/BLOOD MUSCLES/BONES/ JOINTS/SKIN BLADDER/KIDNEY STOMACH/ INTESTINES/BOWELS IMMUNE PROBLEMS OTHER HEALTH CONCERNS HEARING
CONCERNS Hearing aides? Preferential seating?
VISION CONCERNS Glasses or contacts? Reading only?
GROWTH & NUTRITIONAL CONCERNS DEVELOPMENTAL CONCERNS EMOTIONAL/ BEHAVIORIAL
• Routine or daily medications, treatments or therapies (not listed above): • Activity restrictions in school?
• Special medical equipment required in school? (eg. oxygen, wheelchair)
• Have there been any significant changes in your child’s health over the last year? Explain: • ILLNESSES, HOSPITALIZATIONS, ACCIDENTS/ INJURIES and dates: (use other side if necessary)
Health Care Provider(s) & Phone #:
PARENT/GUARDIAN SIGNATURE HOME/WORK PHONE # DATE completed:
Name of school nurse: _________________________________________ your school nurse can be reached at:
CHILDREN WITH SPECIAL HEALTH CARE NEEDS
Immediately notify school nurse (RN) regarding the following significant student health concerns
Medications
• Injectable (e.g., EpiPen®, insulin, glucagon) • Nebulizer treatments
• Rectal
• Homeopathic preparations
Potential life threatening conditions such as:
• Severe allergies (e.g., insect sting, food, nuts, latex ) • Diabetes
Neurological disorders: • Seizures
• Significant head injuries or concussion (look for time frame) Significant heart conditions
Significant respiratory conditions
• Asthma; where child is on regular medications
• Child who is on oxygen (at home, child care or school) Special health conditions
• Bleeding disorders • Cancer
• Weakened immune system • HIV/Aids; Hepatitis B or C • Organ transplant Special equipment such as:
• Central Line (IV)
• Glucometer (testing blood glucose) • Insulin pump
• Gastrostomy tube • Tracheostomy tube • Catheters (urinary) • Colostomy
• Vagal Nerve Stimulator (VNS) • Wheelchairs or crutches
Other conditions that may require nursing consultation: • Nutritional concerns
• Health resource referral • Infectious disease • Chronic illness • Recent injuries • Recent hospitalization • Hearing/Vision concerns • Hypoglycemia • Migraines
• Special bathroom needs
CONFIDENTIAL
NURSE CONSULTANT ASSESSMENT AND CHECKLIST FOR CHILDREN WITH SPECIAL NEEDS
NAME: __________________________________ BIRTHDATE: _________________
The Children’s Hospital School Health Program, Denver, CO (2004)
Parent/Guardian’s names: Phone during daytime: Address:
Physical Assessment: √ = Normal Indicate if performed by RN or source of records reviewed
Ears, Nose Abdomen
Eyes Genitalia
Mouth, throat Extremities/joints
Lungs Spine
Cardiovascular Blood Pressure
Dental Screening Skin, lymph nodes
Allergies Date______ Height _____ Weight _____ BMI _____
Immunizations Hct. Hgb. Date Vision/Results Date Hearing/Results Nutrition/Diet Current Medications Technology CURRENT HEALTH ISSUES:
PERTINENT HEALTH HISTORY:
Goals/priorities Collaboration/Liaison Communications FAMI LY Other
Health assessment, including student strengths Individualized health care plan
Emergency plans Health status monitoring Specialized health procedure Health teaching/counseling Medication
Personnel training Personnel supervision
Staff consultation- General staff training date: Family support/liaison
Health Care Provider consultation/orders Parent authorization(s)
Release of info to/from health care provider
HEA LTH S E RVI C ES
Other Peer awareness training date: School contacts
Direct caregivers Specific student training date Substitute caregivers/back-up staff Specific student training date:
IM P O RTANT P E RS ONNEL
CONFIDENTIAL
NURSE CONSULTANT ASSESSMENT AND CHECKLIST FOR CHILDREN WITH SPECIAL NEEDS
NAME: __________________________________ BIRTHDATE: _________________
The Children’s Hospital School Health Program, Denver, CO (2004)
Vehicle/Access Special Assistance/Aide Equipment Positioning Emergency Plan/Evacuation/Safety Communications T R A N S P O R TA TI ON Other
Supplemental in-school tutor--regular, intermittent Plan for continuous programming--school/home/hospital Extra set of books at home
Regular home/hospital program
TUTO RI NG/ HOME/ HOS PITAL Other Curriculum/instruction Special Equipment Activities of daily living
Scheduling of health interventions Positioning/Mobility Special diet OTHER PR OGR AM ADAP TATIONS Other
School entrance Hallways Stairs/elevator Personal facilities Bathroom Locker
Health Room Physical Recreation Areas (gym, playground,etc)
Cafeteria Special Classroom
Library Labs ACC ESS Other Evacuation Plan/Practice Back-up plan FI R E SAFET Y Other
Length of day Number of days Rest periods Flexible schedule
S
C
HEDULE
Testing schedule Other
Occupational therapy Social Work
Physical therapy Counseling/Mental Health
THERAP IES RELATE D SERVIC E S
Speech/language pathology Other
Special learning opportunities Extended day program/child care Clubs/Sports/Social Events Transportation/Access E XT RA C URRICUL AR ACT IVIT IE S Other
Medication Plan Designated Staff Trained: Emergency Plan Personnel Transportation F IELD T RIP s Other
Source: Adapted with permission from (C. Perreault), Children with Special Health Care Needs in School and Child Care,
in Pediatric Home Care, 2nd edition, Townsend and Votroubek, eds., 1997, Aspen Publications
The original version of this checklist was published by the Federation for Children with Special Needs as “Checklist of items for consideration in developing IEP’s for students with physical disabilities or special health needs. This adaptation appeared in Serving Students with Special Health Care Needs, Connecticut State Department of Education, 1992. It is used here with permission of both source
PLANNING CHECKLIST FOR IHCP AND IEP DEVELOPMENT
For Students with Special Health Care Needs FAMILY ◊ Goals/priorities ◊ Liaison ◊ Collaboration ◊ Communications ◊ Other HEALTH SERVICES
◊ Health assessment, including student strengths ◊ Individualized health care plan
◊ Emergency plans ◊ Health status monitoring ◊ Specialized health procedure ◊ Health teaching/counseling ◊ Medication ◊ Personnel training ◊ Personnel supervision ◊ Staff consultation ◊ Family support/liaison ◊ Physician consultation/orders ◊ Parent authorization(s)
◊ Release of info to/from health care provider ◊ Other TRANSPORTATION ◊ Vehicle ◊ Access ◊ Safety ◊ Equipment ◊ Positioning ◊ Emergency Plan ◊ Communications ◊ Special Assistance ◊ Evacuation ◊ Aide ◊ Other TUTORING/HOME/HOSPITAL
◊ Supplemental in-school tutor--regular, intermittent ◊ Plan for continuous
programming--school/home/hospital ◊ Extra set of books at home ◊ Regular home/hospital program ◊ Other
OTHER PROGRAM ADAPTATIONS ◊ Curriculum/instruction
◊ Special Equipment ◊ Activities of daily living ◊ Scheduling of health interventions ◊ Positioning ◊ Mobility ◊ Special diet ◊ Other ACCESS ◊ School entrance ◊ Hallways ◊ Stairs/elevator ◊ Classroom/specials ◊ Bathroom ◊ Health Room ◊ Cafeteria ◊ Library ◊ Locker ◊ Gym ◊ Playground ◊ Other FIRE SAFETY ◊ Evacuation Plan ◊ Evacuation practice ◊ Back-up plan ◊ other SCHEDULING ◊ Length of day ◊ Number of days ◊ Rest periods ◊ Flexible schedule ◊ Testing schedule ◊ Other THERAPIES ◊ Occupational therapy ◊ Physical therapy ◊ Speech/language pathology ◊ Other
OTHER RELATED SERVICES ◊ Social Work
◊ Counseling ◊ Psychology ◊ Other
EXTRACURRICULAR ACTIVITIES ◊ Special learning opportunities
◊ Extended day program ◊ Clubs ◊ Sports ◊ Social Events ◊ Transportation ◊ Access ◊ Other FIELD TRIPS ◊ Medication Plan ◊ Emergency Plan ◊ Personnel ◊ Transportation ◊ Other
SCHOOL INTAKE INTERVIEW - DIABETES
Student ____________________________________________________ Date of birth ____________________ School _____________________________________ Grade _____ Homeroom Teacher __________________ Parent(s)/Guardian(s) _______________________________________________________________________ Phone (H) _______________________ (W) _______________________ (Other) ________________________ Emergency contact (other than parent /guardian) ________________________ Phone _________________ Physician name __________________________ Office Phone _________________ Fax _________________ Diabetes Nurse Educator’s name ____________________________ Office Phone ______________________ Medical release of information signed? Yes ___ No ___
Mode of transportation to and from school? ___________ Bus driver notified of diabetes? Yes ___ No ___ Does child participate in after school activities? Yes ___ No ___ Before ___ or after ___ care? Explain ____________________________________________________________________________________ Adult leader notified of diabetes? Yes ___ No ___
Field trip recommendations: __________________________________________________________________ Blood Sugar Monitoring:
Test will be performed in ____________________________ (location).
Needs assistance with testing? Yes ___No ___ Explain __________________________________ Required test times _________________________________________________________________ Call parent if blood sugar below _______ or above _______
Staff to record values and report to parents daily ____ weekly ____
Comments: _________________________________________________________________________________ Meds: Insulin: Can child give own injections? Yes ___ No ___ Explain ____________________________
Order for insulin on file? Yes ___ No___
Time(s) insulin is to be administered at school: _________________________________________ Type/Dosages: ______________________________________________________________________ Form of administration: _____________________________________________________________
(Injection, Pen, Pump)
Oral medications: Type _________________ Times _________________ Dose ________________ Comments: _________________________________________________________________________________
Diet: Assigned student lunch time(s)? _____________________________
Is child following a prescribed meal plan? Yes____ No____ Assistance required? Yes ___ No ___ Explain____________________________________________________________________________ ___________________________________________________________________________________ Snack time(s)? __________________________________ Assistance required? Yes ___ No ___ Explain____________________________________________________________________________ Snack will be eaten in __________________ (location)
Snacks will be stored in ________________ (location)
Recommended snacks________________________________________________________________ Parent wishes to be notified in advance of class parties? Yes ___ No ___
Child may partake in class treats? Yes___ No ___ Explain ________________________________ Comments: _____________________________________________________________________________ Physical Education:
Scheduled at:__________
Is snack necessary before physical education? Yes ___ No ___
Does child participate in after school sports? Yes ___ No ___
P.E. Teacher/Coach aware of child’s diabetes? Yes ___ No ___
The Children’s Hospital School Health Program, Denver, CO 2005
QUESTIONNAIRE FOR PARENT OF A STUDENT WITH ALLERGIES
It has come to our attention that your student has allergies. The school nurse needs more information on your student's allergies to help us take care of your student at school. Please complete this form and return to school. If you have any questions about how to complete this form, please contact your student’s school nurse. Nurse’s Name: Phone:
Student Name: Birth date
Parent/Guardian Name & Phone#: Parent/Guardian Name & Phone#:
Other Emergency Contact Name & Phone#: Primary Care Provider & Phone#:
Allergy Care Provider & Phone#: Preferred Hospital:
1. What is your student allergic to? How severe is your student’s allergic reaction?
Foods (specify type _________________) □Mild; □Moderate; □Severe; □Other _____________________ Foods (specify type _________________) □Mild; □Moderate; □Severe; □Other _____________________ Foods (specify type _________________) □Mild; □Moderate; □Severe; □Other _____________________ Insect sting (specify type ___________) □Mild; □Moderate; □Severe; □Other _____________________ Animals, pets (specify type ___________) □Mild; □Moderate; □Severe; □Other _____________________ Latex □Mild; □Moderate; □Severe; □Other _____________________ Pollens (grass, flowers, trees) □Mild; □Moderate; □Severe; □Other _____________________ Dust, dust mites □Mild; □Moderate; □Severe; □Other _____________________ Mold □Mild; □Moderate; □Severe; □Other _____________________ Medications □Mild; □Moderate; □Severe; □Other _____________________ Other (specify _________________ ) □Mild; □Moderate; □Severe; □Other _____________________ 2. If your student has a food allergy can he/she be in the presence of others eating the food? YES NO
3. When was your student first diagnosed? _________________________________________________________________ 4. Was allergy testing done? YES NO; If YES, what kind: □RAST(blood) □Skin □Other:______________________ Test results:___________________________________________________________________________
5. When was your student’s last significant allergic reaction? ____________ What allergy caused the reaction? ________ 6. What symptoms occurred? Hives; Rash; Swelling/itching of lips, tongue, mouth, face; Throat tightness;
Cough; Wheezing; Shortness of breath; Nausea; Cramps; Vomiting; Diarrhea; Other: ________ 7. Please list the medications your student takes (every day and as needed) or include a copy of your student's Allergy Action
Plan.
MEDICATIONS TAKEN AT HOME
Medication Name? How Much? When is it taken?
MEDICATIONS TO BE TAKEN AT SCHOOL*
Medication Name? How Much? When is it taken?
8. Does your child’s allergy care provider recommend that your child carry and self administer his/her own medication? _Yes _No _Don't know
9. Can this information be shared with classroom teacher(s) and other appropriate school personnel? YES NO
*I understand that I need a permission form for each medication my child needs to take at school signed by myself and my child’s health care provider (a signed Allergy Action Plan will suffice).
QUESTIONNAIRE FOR A PARENT OF A STUDENT WITH ASTHMA OR BREATHING PROBLEMS
It has come to our attention that your child has asthma or breathing problems. The school nurse needs more information on your child's asthma to help us take care of your child at school. Please complete this form and return to school. If you have any questions about how to complete this form, please contact your child’s school
nurse. Nurse’s Name: Phone:
Student Name: Birth date
Parent/Guardian Name & Phone#: Parent/Guardian Name & Phone#: Other Emergency Contact Name & Phone#: Primary Care Provider & Phone#: Asthma Care Provider & Phone#: Preferred Hospital:
1. On a scale of 1-5, rate how severe your child’s asthma is, where 1 = not severe and 5 = severe. 1 2 3 4 5 Please circle
2. How many times has your child been treated in the emergency department or hospitalized for asthma in the past 12 months? _0 times _1 time _2 times _3 times _4 times _5 or more times
3. What triggers your child's asthma or makes it worse?
Pollens (grass, flowers, trees) Cigarette smoke Exercise, sports Mold Having a cold, sinusitis Animals, pets Chalk, chalk dust Changes in weather Cockroaches Foods, medications Paints, cleaning agents, new furnishings Stress, emotional upsets Dust, dust mites
Strong odors, perfume, dry-erase markers Other_______________
4. Does your child use a peak flow meter (something he/she blows into to check his/her airway)?
_Yes _No _Don't know
5. Do you know what your child's personal best peak flow number is? _Yes What is it? _________ _ No 6. Please list the medications your child takes for asthma or allergies (every day and as needed) or include a
copy of your child's Asthma Action Plan.
MEDICATIONS TAKEN AT HOME
Medication Name? How Much? When is it taken?
MEDICATIONS TO BE TAKEN AT SCHOOL*
Medication Name? How Much? When is it taken?
7. How well does your child take his/her asthma medications?
_Takes medicine by self as prescribed _Often forgets to take medicine _Needs help to take medicine _Not using medicine now
8. Does your child’s asthma care provider recommend that your child carry and self administer his/her own medication? _Yes _No _Don't know
9. Can this information be shared with classroom teacher(s) and other appropriate school personnel? YES NO
*I understand that I need a permission form for each medication my child needs to take at school signed by myself and my child’s health care provider (a signed Asthma Action Plan will suffice).
ADDITIONAL QUESTIONS FOR PARENT OF A STUDENT WITH ASTHMA OR BREATHING PROBLEMS 10. For each season of the year, to what extent does your child usually have asthma symptoms?
(Mark an X for each season below.)
A lot A little None
Fall Winter
Spring Summer
11. Does anybody in the household smoke? _ Yes _ No
12. In the past month, during the day, how often has your child had coughing, wheezing, or breathing difficulties?
13. _ 2 times a week or less _ More than 2 times a week _ Every day (at least once every day) _ Constantly (most or all of the time, every day)
14. In the past month, during the night, how often does your child wake up or have coughing, wheezing, or breathing difficulties?
__2 times a month or less _More than 2 times a month _More than 2 times a week _Every night 15. How many times do you refill your child’s prescription for quick-relief canisters each year? _________ 16. Does your child have a written Asthma Action Plan? _Yes _No _Don't know
17. Does your child usually use a spacer or holding chamber with his/her metered dose inhaler (a clear tube that attaches to the inhaler and better helps the inhaled medicine get into the lungs)?
_Yes _ No _ Don't know _ He/she uses a dry powdered inhaler, so spacer not needed
18. Do you use anything else for your child’s asthma (tea, herbs, home remedies, etc.) beside the medications listed? _______________________________________________________________
19. During the past year, how much has your child's asthma stopped him/her from taking part in sports, recess, physical education, or other school activities?
__Never _Once in a while _Fairly often _Frequently
Adapted from: NASN School Nurse Asthma Management Program (SNAMP) Resource Manual CD-ROM “Worksheet for Gathering Information from Parent/Guardian About Student with Asthma or Suspected Asthma” and Minneapolis Public Schools Healthy Learners
School District Logo
Confidential Individualized Health Care Plan/ School Year Pg of 1 School Nurse Name & Phone Number (School Fax)
Student Name DOB School/Grade Student #
Parent/Guardian: Name & Phone # Parent/Guardian: Name & Phone #
Authorized Health Care Provider Primary & phone # Authorized Health Care Provider Specialist & phone # Preferred Hospital:
HEALTH CONCERN:
HISTORY: (brief history and background if pertinent)
CURRENT MEDICATIONS:
ALLERGIES: if relevant
ACTIVITY RESTRICTIONS: if relevant
GOAL:
SYMPTOMS:
INTERVENTIONS: (what to do)
SAFETY: evacuation plan
As parent/guardian of the above named student, I give my permission for use of this plan in my child’s school and for the school nurse to contact the above named health care provider regarding this health care plan.
______________________________ ___________________________
parent/guardian date student (optional) date
_____________________________________________ _________________________________________
health care provider date school nurse date
_____________________________________________
Criteria for Determination of Delegation to UAP in the School Setting
Student: ________________________________________ School: ______________________ Grade: _______ Task for review: ______________________________________________________________________
Elements for
Review Circle the appropriate answer Comments
Within the delegating nurse's area of responsibility? Yes or No
Within the knowledge, skills and ability of the nurse delegating the task? Yes or No Nursing Assessment:
Level of Client Chronic/stable/predictable
Stability Minimal potential for change Moderate potential for change
Unstable or strong potential for change
Level of UAP's UAP knowledgable and experienced in task to be delegated
Ability to Perform UAP has minimal knowledge/experience but willing and able to learn task
Task UAP not available,willing, or able to perform task to be delegated Number of UAP available to perform delegated task
Number of UAP necessary to perform delegated task safely
Level of Decision- Does not require decision making
Making Required Minimal level of decision making
of UAP Moderate to High level of decision making Has a predicatable outcome
Complexity of Unit dose
Delegated Task Minimal steps Multi-steps required
Potential Risk of None
Delegated Task Low Medium High
Risk of harm for student if task not delegated
Degree of None
Invasiveness Low
with Task Medium High
Frequency of task Performed daily
to be performed Performed at least weekly
by UAP Performed at least monthly Performed less than monthly
Available but may never be performed
Approximate Average 3 minutes or less
EMS Response Average 3-10 minutes
Time Average greater than 10 minutes
Ability for Client Will never be able to perform task
to Learn and Will require extensive assisstance
Perform Task Will require limited assisstance
Will be able to perform task independently
Determination to Delegate: Yes or No
Nurse Signature: _______________________________________________________ Date: ____________ Adapted from National Council of State Boards of Nursing (Regulation - Delegation and UAP issues)
by Jefferson County School District - Department of Health Services
Has the RN completed an assessment of student's nursing care needs?
Do assessment, then consider of delegation.
NO
Is the task within the RN's scope of practice? Do not delegate.
Is the task reasonable and prudent and consistent with
the student's health and safety? Do not delegate.
Has the RN validated the delegatee is trained and competent to do the task?
Do not delegate.
Provide and document training, then consider delegation.
OR
Are the consequences of improper task performance life threatening for the student?
Does the task require nursing judgment or repeated nursing assessments?
Does the task involve complex observations or critical decisions by the delegatee?
Is the task of a routine, repetitive nature requiring exact unchanging directions?
Are the results of the task reasonably predictable?
Is the RN able to provide appropriate supervision?
Does the RN's agency have a policy which allows delegation of this task to the delegatee?
The task may be delegated to a specific delegatee for this student ONLY
NO NO Do not delegate. Do not delegate. Do not delegate. Do not delegate. Do not delegate. Do not delegate. Do not delegate. NO NO NO NO NO NO NO NO YES YES YES YES YES YES YES YES YES YES YES
DELEGATION DECISION TREE*
The Children's Hospital School Health Program, Denver, CO 2005
Procedures Requiring Delegation and/or Training to Unlicensed School Personnel Procedure Medical Order Needed RN Task RN Train/ Delegation Needed Minimum Review of Competency RN to Instruct Other Staff
Activities of Daily Living (ADL)
Toileting/Diapering No Yes No Yes
Toilet Training No Yes No Yes
Dental/Oral Hygiene No Yes No Yes
Lifting/Positioning No Yes No Yes-OT/PT to
assist Feeding
Oral No Yes No Yes
NG Tube
(bolus/slow drip)
Yes Yes Yes Yearly -
G-tube (bolus slow drip)
Yes Yes Yes Yearly -
J-tube (bolus/slow drip)
Yes Yes Yes Yearly -
IV TPN feeding Yes Yes No -
NG Insertion Yes Yes No -
NG Removal Yes Yes No-ER only -
GT Reinsertion Yes Yes No -
Catheters Clean Intermittent
Cath
Yes Yes Yes Once a
semester
-
Sterile Cath Yes Yes Yes Once a
semester
-
Indwelling Cath Care
Yes Yes Yes Once a
semester
-
Crede Cath Care Yes Yes Yes Once a
semester
-
Medical Support VP Shunt
monitoring
Yes Yes Yes Yearly -
VP Shunt –pumping Yes Yes
in ER
No -
Mechanical Ventilator
Monitor Vent Yes Yes Yes Once a
semester
-
Adjust vent Yes No No -
Vent equipment failure Yes Yes-in ER No - Pulse Oximeter Monitoring
Yes Yes Yes-with
parameters
Once a semester
Procedures Requiring Delegation and/or Training to Unlicensed School Personnel Procedure Medical Order Needed RN Task RN Train/ Delegation Needed Minimum Review of Competency RN to Instruct Other Staff Intermittent Oxygen
Yes Yes Yes-with
parameters Once a semester - Continuous/monitor oxygen
Yes Yes Yes-with
parameters
Once a semester
-
IV’s
Hickman/Broviac Yes Yes No -
Central Line Yes Yes No -
Heparin Lock Yes Yes No -
IV dressing change Yes Yes No -
Peritoneal Dialysis Yes Yes No -
Apnea Monitor Yes Yes Yes Once a
semester
-
Ostomies
Ostomy Care Yes Yes Yes-ER
only
-
Ostomy Irrigation Yes Yes No -
Dressing Changes
Sterile Yes Yes No -
Decubitus Ulcer Care
Yes Yes No -
Respiratory
Postural Drainage Yes Yes Yes Yearly RT to aid
Chest Percussion Yes Yes Yes Yearly OT/.PT/RT
may assist Suctioning
Oral/Nasal Yes Yes Yes Once a
semester
-
Trach Yes Yes Yes-no deep
suctioning
3 months -
Trach tube replacement
Yes Yes No -
Trach Care Yes Yes No -
Diabetic Care Blood Glucose
Testing
Yes Yes Yes Once a
semester
-
Ketone Testing Yes Yes Yes Once a
semester
-
Insulin Injections Yes Yes Yes-with
parameters
3 months -
Glucagon injection Yes Yes Yes 3 months -
Procedures Requiring Delegation and/or Training to Unlicensed School Personnel Procedure Medical Order Needed RN Task RN Train/ Delegation Needed Minimum Review of Competency RN to Instruct Other Staff *Routine Medications
Oral Yes Yes Yes Yearly -
Epipen Yes Yes Yes Yearly -
Inhalers Yes Yes Yes Yearly -
Nebulizer treatments
Yes Yes Yes Yearly -
Ear/Eye Drops Yes Yes Yes Yearly -
Topical Yes Yes Yes Yearly -
**Non- Routine Medications
Injection-SQ Yes Yes Yes 3 months -
Injection-IM Yes Yes No -
Rectal Yes Yes Yes 3 months -
NG Meds Yes Yes Yes Yearly -
IV Meds Yes Yes No -
Spirometry Yes Yes Yes Yearly -
Development of:
HCP - Yes NA -
Emergency Plans - Yes NA -
IEP Heath Objectives
- Yes NA -
*Routine medication administration is addressed in the Medication Administration Instructional Program. (link to medication) This manual and curriculum is designed to give unlicensed personnel basic information in the administration of medication. Training alone does not constitute delegation. After completion of training
unlicensed personnel must demonstrate competency in the performance of the task of medication administration.
** Non-routine medications require 1:1 delegation, if it is appropriate to delegate such medications for a child with a stable condition. This will be based on individual situations utilizing the current HCP for the child.
Note: For adequate coverage, it is recommended that each of these procedures be delegated to at least 3 staff members.
Adapted from The Medically Fragile Child in the School Setting, American Federation of Teachers, Second edition.
