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Individualized Healthcare Plan: Ventriculo-Peritoneal Shunt
School year:
Name:
DOB:
I.D.
Grade:
Parent/Guardian:
Home Phone:
Work Phone:
Emergency Contact:
Phone:
Primary Physician:
Phone:
Specialist Physician:
Phone:
Medical Diagnosis:
Related Nursing Diagnoses: 1. Potential for injury R/T increased intracranial pressure
2. Potential for infection R/T presence of shunt
3. Alteration in activity tolerance R/T presence of shunt
Medications: Home
School
Anticipated side-effects:
Brief description: A ventricular-peritoneal shunt provides mechanical drainage for
cerebrospinal fluid (CSF) from the ventricles in the brain to the peritoneum
(abdominal cavity). V-P shunts relieve pressure on brain tissue caused by an
accumulation of CSF due to an obstruction in the ventricular system. Causes of
obstruction may include tumors, meningitis, intraventricular hemmorhage, trauma,
and developmental abnormalities. Hydrocephalus (enlarging of the skull) may result
if obstruction occurs before cranial sutures fuse. Two potential complications of
shunts are infection and malfunction.
Student history:
Age at placement:
Type and location of shunt:
Date of last revision of shunt:
Intellectual, physical, neurologic limitations R/T diagnosis:
Expected Outcomes R/T Education: With effective management of shunt status
student will 1) participate in regular classroom activities, 2) participate in appropriate
physical education and recess activities, 3) minimize absences due to shunt
complications.
Plan at School:
1. Student will maintain optimal shunt function
 Parent/guardian will ensure student follows prescribed medical
regimen including regular appointments and timely revision of shunt
 Parent/guardian will inform staff of necessary precautions,
signs/symptoms that may indicate complications
Individualized Healthcare Plan 2
2. Nursing Interventions
 instruct teachers/staff in safety precautions R/T presence of shunt
(avoid contact sports; blow to head need immediate medical attention)
 inform teachers/staff of signs/symptoms of shunt malfunction
(Headaches, stomach discomfort and/or vomiting, lethargy, seizures,
irritability, swelling along shunt tract, decreased school performance)
 inform teachers/staff of signs/symptoms of infection (redness along
shunt tract, fever, neck stiffness, light sensitivity, headache, signs of
malfunction
 communicate with student’s physician as necessary
Emergency Plan:
Call parent/guardian for any symptom listed in #2.
References:
Fried, A.H. & Epstein, M.H.. Treatment of hydrocephalus: shunts. World Wide Web URL
accessed 4-1-05: VirtualTrials.com/index.ctm.
Haas, M.K. (ed.), Villars Gerber, M.L., Kalb, K.M., Luehr, R.E., Miller, W.R., Silkworth, C.K., &
Will, S.I.S. (1993). The School Nurse’s Source Book of Individualized Healthcare Plans. North Branch,
MN: Sunrise River Press.
School District of Holmen: Individual Health Plans. World Wide Web URL accessed 1-23-03:
http://www.holmen.k12.wi.us/District/DistrictInformationalServices/health services/ihp%20info.htm
VDH Nursing Council School Health Committee: Individualized Healthcare Plans. World Wide
Web URL accessed 1-23-03: http://www.geocities.com/schoolnursing/ihp.htm
IHP prepared by: _______________________________ Date:________________
IHP review dates: ___________ ___________ ___________ ___________
I have reviewed and agree with this Individual Health Plan:
__________________________________________________________________
Parent/guardian signature
Date
__________________________________________________________________
School Nurse signature
Date
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