As the practice of school nursing expands in complexity, the need to communicate the outcomes of the care provided becomes more important. The Individualized Healthcare Plan (IHP) is a variation of the time-honored nursing care plan adapted specifically to school nursing. It communicates nursing care needs to regular and special education administrators, teachers, Health Assistants, and parents.

An IHP helps to ensure that all necessary information, needs, and plans are considered to maximize the student's participation and performance in school. The Public Education Department (PED)-licensed School Nurse establishes the type, amount, and intensity of nursing care required by a particular student. The IHP 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.

Benefits of an IHP include quality assurance of school nursing services, continuity of care, and development of a safer delegation process of nursing in the school setting.

Indications

Students with any of the following conditions, but not limited to these conditions, may need an Individualized Healthcare Plan.

• Allergies
• Anorexia Nervosa
• Asthma
• ADHD
• Autism
• Bulimia
• Cerebral Palsy
• Congenital Heart Disease
• Cystic Fibrosis
• Depression
• Diabetes Mellitus
• Down Syndrome
• Duchenne Muscular Dystrophy
• Hearing Impairment
• Hemophilia
• Illness — possibly terminal
• Obesity
• Seizure Disorder
• Spina Bifida
• Visual Impairment

Guidelines

The first step should be an assessment of health needs that may indicate the need for an Individualized Healthcare Plan (IHP). The following is an assessment checklist:

When the certified licensed School Nurse determines that an Individualized Healthcare Plan is needed, it must address the following identifiable parts:

• History.
• Assessment data.
• Nursing diagnosis.
• Goal of care, including student, family, and physician goals.
• Selected nursing actions or interventions.
• Expected student outcomes.
• Evaluation of the plan of care.

History: This is the first step in the assessment process. Collecting data from the family, physician, and student when appropriate, is essential.

Assessment Data: It is essential for the School Nurse to do a physical evaluation of the student. See the Screening/Assessment section for detailed information.

Nursing Diagnosis: This is a method of organizing and summarizing nursing data to define the student's health. See sample nursing diagnoses at the end of this section.

Goal of Care: Goals are broad-based statements that address the educational relevancy of the Individualized Healthcare Plan. See examples at the end of this section.

Selected Nursing Actions or Interventions: These are actions taken to achieve a desired student outcome.

Expected Student Outcomes: These are statements that describe how a student's situation will be different or healthier as a result of the nursing interventions received.

Evaluation of the Plan of Care: The plan must be reviewed annually or whenever a change in status is noted.

The Individualized Healthcare Plan (IHP) needs to be signed by the parent/guardian indicating their acknowledgement of the IHP. The nurse needs to keep a copy of the IHP in their working files. The IHP needs to be shared with pertinent school personnel. If the student has an Individualized Education Program (IEP), the Individualized Healthcare Plan must be included.

Nursing Diagnosis

NANDA has 244 nursing diagnoses. These are updated every three years. Per the North American Nursing Diagnosis Association (NANDA):

There is no real use for simply providing a list of terms — to do so defeats the purpose of a standardized language. Unless the definition, defining characteristics, related and/or risk factors are known, the label itself is meaningless. Therefore, we do not believe it is in the interest of patient safety to produce simple lists of terms that could be misunderstood or used inappropriately in a clinical context.

Nanda International Knowledgebase. (n.d.). Does NANDA International provide a list of its diagnoses on its website? Retrieved July 22, 2022, from http://nanda.host4kb.com/article/AA-00232.

A School Nurse health plan book may help in choosing nursing diagnoses that fit your student. Many nurses and districts create plan templates and then individualize them per student.

Four types of nursing diagnoses are frequently used in the school health setting. The distinction between these types of nursing diagnoses is how they are used to describe the status of the problem. The four most frequently used in the school setting are actual, risk, wellness, and health.

An actual nursing diagnosis describes response to a health condition. It is supported by signs and symptoms that are manifested in the student. Examples of actual nursing diagnoses include ineffective airway clearance, disturbed body image, and impaired tissue integrity.

A risk nursing diagnosis describes the response to a health condition. This is supported by risk factors seen in the student as opposed to signs and symptoms. Examples of risk nursing diagnoses are risk for unstable blood glucose, risk for compromised resilience, and risk for aspiration.

The health promotion nursing diagnosis describes the clinical judgement of a student’s readiness or motivation to increase well-being and readiness to enhance or increase health behaviors. These diagnoses are supported by defining characteristics of the health behaviors. Examples of health promotion nursing diagnoses are readiness for enhanced self-health management, readiness for enhanced nutrition, and readiness for enhanced coping.

The wellness nursing diagnosis describes students’ progress or potential progress toward healthier behaviors rather than on a problem. It is validated by defining characteristics such as signs and symptoms. Examples of wellness nursing diagnoses are similar to those of a health promotion diagnosis in using the readiness diagnoses: readiness for enhanced self-care, readiness for enhanced sleep, and readiness for enhanced knowledge.

See Selekman, J., et al. (2013). School nursing: A comprehensive text. F. A. Davis Company, p. 292.

Care/Educational Goals

Student will:

• Maintain health, safety, and well-being necessary for learning and consistent school attendance.
• Increase or maintain independence in a safe school environment.
• Cooperate with medical treatment plan during the school day.
• Increase independence and responsibility for management of own health-care needs at school.
• Increase independence in safe and responsible self-administered medication/treatments ordered during the school day.
• Maintain health/state of wellness that enhances educational potential and school attendance.
• Participate in instruction, health education, and health counseling to promote effective self-health care management at school.
• Assist in reduction of risk of injury or medical emergency at school and during off-campus school activities.
• Increase socialization skills, self-image, attention, and alertness necessary for optimum participation in the total school program.
• Increase availability to learning/instructional time necessary to meet educational objectives.
• Participate in collaborative health services to facilitate optimum health and safety necessary for educational progress.
• Cooperate with local district policy for control of communicable disease and collection of up-to-date medical information necessary for optimum health and well-being at school.
• Provide current medical orders and medical reports for all health conditions, medications, and treatments required during the school day.

Information to Include in an IHP

See below for information to include in an Individualized Healthcare Plan:

From Selekman, J., et al. (2013). School nursing: A comprehensive text. F. A. Davis Company, p. 292.

School Nurse Chronic Assessment Tool (CHAT)

Per the Agency for Healthcare Research and Quality, chronic health is defined as a physical or mental health condition that lasts more than one year and causes functional restrictions or requires ongoing monitoring or treatment. Chronic diseases are among the most prevalent and costly health conditions in the United States. Approximately 45%, or 133 million, Americans suffer from at least one chronic disease, and the number is growing.

Approximately 25% of students enrolled in schools have a chronic health condition with essential need for care planning and care coordination by a school nurse. Managing Chronic Health Conditions in Schools: The Role of the School Nurse notes that it is vitally important for a school nurse to use assessment and critical nursing judgement to prioritize which students are at highest risk for an emergency and need a care plan. Equally important, it is essential for the school nurse to coordinate the student’s care in partnership with the parent/guardian, the student, the healthcare team, and school staff, and to develop emergency care plans and coordinate training.

The National Association of School Nurses’ Framework for 21st Century School Nursing Practice places the student at the center of care, with care coordination as one of the four components of school nursing care. To support the development of care, school nurses in the state of Missouri created the School Nurse Chronic Health Assessment Tool (CHAT®) to assist school nurses in gathering information about students who have chronic health conditions.

CHAT® assists the school nurse in guiding conversations with parents and caregivers, contains learning guides for specific chronic health conditions, and care plans for four conditions. CHAT® contains four chronic health condition intake assessments, health care plans, and emergency health care plans for asthma, diabetes, seizure, and sickle cell disease.

To order the free tool, visit the School Nurse Chronic Health Assessment Tool – SN CHAT – Allergy & Asthma Network Store. Please note, once ordered, the document is ready for immediate download. Ordering requires contact information and allows the program to know how often the resource is being used. There is no cost.

Primary Editors: Crista Pierce, BA, RN, CLNC, ADA, School Health Advocate, SW Region, New Mexico Department of Health

Secondary Editors: Kate LaRose, BSN, RN, School Health Advocate, NE Region, New Mexico Department of Health; Susan Acosta, BS, RN, NCSN, State School Health Consultant, New Mexico Department of Health