Individualized Health Care Plan Planning Form

Demographics

Student Name Zoelle Mirth Birth Date January 4, 2008

Home Address 5223 Topaz Drive, Hudson Ohio, 44236

Parent/Guardian Kate Johnson Phone 330-329-4682

Parent/Guardian TIm Mirth Phone 330-329-4444

Caregiver Kate and TIm, parents

Language spoken at home English

Emergency Contact: Kate Mirth Mother 330-329-4683

Name Relationship Phone

Medical Care Primary Physician Dr. Shaw Phone 330-555-555

Specialty Physician_______________________________________________________ Phone _________________

Specialty Physician_______________________________________________________ Phone _________________

Health History

Brief health history Zoelle is a 10 year old female with a history of Asthma. She was diagnosed with reactive airway as an infant and officially
diagnosed with asthma around the age of 4. Her asthma is exacerbated by respiratory illness and exercise.

Special health care needs She will need albuterol as needed at school.

Other considerations She will need to take her albuterol prior to gym, she also participates in soccer after school will need to take prior to
practice.

Student’s Ability to Participate in Care

Rose uses her albuterl with a spacer with minimal assistance. She is managing her symptoms very well this year.
Allergies

No food or known drug allergies.

​Medication & Dietary Needs

Flovent 2 puffs BID, with spacer

Albuterol 2 puffs every 4 to 6 hours as needed for coughing, wheezing or shortness of breath

Zyrtec 10mg daily PO

Special Dietary Requirements

No dietary restrictions

Procedures

Procedure Administer albuterol via spacer

Frequency Prior to gym Times 2 puffs

Position of student during procedure N/S

Ability of student to assist/perform procedure: More independent with medication administration

Location for procedure In nurse clinic

Equipment needed __________________________________________________________________________________________________

__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________

Procedural considerations & precautions ________________________________________________________________________________

__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________

Staff qualified/trained to assist with procedure: ScHool Nurse

Medical Orders for Specialized Health Care Procedures

Student Name Zoelle Mirth Birth Date January 4, 2008

Home Address 5223 Topaz Drive, Hudson Ohio, 44236

Parent/Guardian Kate Mirth Phone 330-329-4682

Name/description of specialized health care procedure ALbuterol 20 minutes prior to gym

Time or indication for procedure 20 minutes prior to gym

Precautions, potential complications & needed actions: Use with spacer, 2 puffs, 20 minutes prior to gym, may cause shakiness or possible
increased heart rate.

Person(s) authorized to perform procedure

x School Nurse xTrained School Staff x Student

Transportation Plan for Student with Special Health Care Needs

Student Name Zoelle Mirth Birth Date January 4, 2008

Home Address 5223 Topaz Drive, Hudson Ohio, 44236

Parent/Guardian Kate Johnson Phone 330-329-4682 School year 2019 to 2020 Review Date 11/3/2019

1. Adaptations/Accommodations Required
_____ Transportation Aide _____ Bus lift _____ Seat belt _____ Special restraint _____ Wheelchair tie down
Space for equipment: specify ________________________________________________________
________________________________________________________________________________
2. Positioning or Handling Requirements
_____ None _____ Describe _____________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
3. Behavior Considerations
x None _____ Describe _____________________________________________________________________________________
____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
 Individualized Healthcare Plan
Student Name: Zoelle Mirth DOB:12/4/2008 School: Blueberry Elementary School Grade: 5

Summary of Health Condition: Zoelle is a 10 year old female with a history of Asthma. She was diagnosed with reactive airway as an infant and
officially diagnosed with asthma around the age of 4. Her asthma is exacerbated by respiratory illness and exercise.

Plan effective ​from 2019 to 2020

Date Health Need Student Goals Interventions Outcomes Evaluation/Progress

(Nursing Dx) Notes
11/3/2019 Risk for activity Student will know Administer 2 puffs of Student will be able to RN spoke to student

intolerance the signs and albuterol 20 minutes prior participate in gym and gym teacher,

symptoms of asthma to gym class class denies symptoms

and take measures during class. Denies

to prevent the wheezing, SOB or

occurrence of difficulty breathing.

symptoms Student able to self

administer

appropriately.
Nurse Signature Initials Nurse Signature Initials
School Nurse SN
 Daily Log

Student Name Zoelle Mirth Birth Date January 4, 2008

Home Address 5223 Topaz Drive, Hudson Ohio, 44236

Parent/Guardian Kate Johnson Phone 330-329-4682

Date/Time Procedure notes Observations Time for Prep, Completed by

Proc, Doc
11/3/2019, 1045 2 puffs of albuterol per physican Student self administered Medication School Nurse Kate
order 20 minutes prior to gym class with RN present. Administration
Tolerated well. Returned
to class. Gym class in 20
minutes.

Nurse Signature Initials Nurse Signature Initials

School Nurse SN