LONG QT SYNDROME IHP Student's Name * First Middle Last Suffix This field is required. Please complete the following fields: First,Last. PhotoAccepted file types: jpg, gif, png, jpeg, Max. file size: 100 MB.DoB Month Incorrect Value for Month field Day Incorrect Value for Month field Year Incorrect Value for Month field Please enter a valid date. GR/LevelDaycareEEPKKN010203040506070809101112Post-GraduateWould you like to add the student's ID number? Yes No ID Campus/Building Would you like to add the student's homeroom number and teacher's name? 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Yes No ContactContact Name Add RemoveRelationship Add RemoveContact Phone Number Add RemoveContact Phone Type Add RemoveContact Phone Number Add RemoveContact Phone Type Add RemoveContact Name RelationshipChoose one:ParentGuardianOtherContact Phone Number Contact Phone TypeChoose OneHomeMobileWorkFaxContact Phone Number Contact Phone TypeChoose OneHomeMobileWorkFax Add More Treating Physician Add RemovePhysician Phone Number Add RemovePhysician Fax Number Add RemoveTreating Physician Physician Phone Number Physician Fax Number Add More Preferred Hospital City MEDICAL DIAGNOSIS(ES)Add a medication or procedure? Yes No MEDICATIONS/PROCEDURES Medication/Procedure Strength Dose ModeChoose one:OralTopicalInhaledIntranasalSQNebulizerSublingualRectalIMIVSched/PRN?Choose OneScheduledPRNTime Frequency If PRN, administer for Medication/Procedure Add RemoveStrength Add RemoveDose Add RemoveMode Add RemoveSched/PRN? Add RemoveTime Add RemoveFrequency Add RemoveIf PRN, administer for Add Remove Add More MEDICAL HISTORYASSESSMENT NursingList InterventionList OutcomesList Nursing Diagnosis: Risk for Decreased Cardiac Output Related to prolonged QT interval increasing the risk of arrhythmias Related to potential for ventricular tachycardia or sudden cardiac arrest Interventions The school nurse will monitor for signs of arrhythmia, such as dizziness, palpitations, or fainting, and act promptly. The school nurse will ensure an automated external defibrillator (AED) is accessible and that staff are trained in its use. The school nurse will collaborate with the student’s healthcare provider to implement an emergency action plan (EAP). The school nurse will educate the student and staff to recognize early symptoms of arrhythmias and the importance of immediate reporting. Expected Outcomes The student will remain free from arrhythmias during the school day. School staff will demonstrate understanding of the emergency action plan. Nursing Diagnosis: Risk for Activity Intolerance Related to limited ability to tolerate physical exertion without triggering arrhythmias Related to fear of symptom onset during physical activity Interventions The school nurse will collaborate with the healthcare provider to determine safe activity levels and restrictions. The school nurse will educate the student, caregivers, and staff about appropriate physical activities and warning signs to monitor. The school nurse will provide the student with rest breaks during physical activities to prevent overexertion. The school nurse will ensure close monitoring during physical education classes and school sports. Expected Outcomes The student will participate in physical activities safely within prescribed limits. The student will report no symptoms of fatigue or dizziness during activity. Nursing Diagnosis: Risk for Ineffective Coping Related to fear of sudden cardiac events Related to imitations on activities compared to peers Interventions The school nurse will offer emotional support to the student and caregivers to address fears and anxieties. The school nurse will encourage participation in non-strenuous activities that foster a sense of inclusion and confidence. The school nurse will refer the student to counseling services if anxiety significantly impacts daily life. The school nurse will connect the family with support groups or resources for individuals with LQTS. Expected Outcomes The student will demonstrate effective coping strategies for managing stress and limitations. The student will report feeling more confident and less anxious about their condition. Nursing Diagnosis: Risk for Knowledge Deficit Related to lack of understanding about LQTS and its management Related to unawareness of emergency procedures or triggers Interventions The school nurse will provide age-appropriate education to the student about their condition, triggers, and symptom management. The school nurse will educate caregivers and staff about LQTS, including recognizing symptoms and implementing the EAP. The school nurse will offer visual aids or handouts that outline safe activities, medications, and emergency protocols. The school nurse will ensure all school staff are trained in CPR and AED use. Expected Outcomes The student, caregivers, and staff will demonstrate understanding of LQTS and its management. The student will adhere to safety precautions and report any symptoms promptly. Nursing Diagnosis: Risk for Ineffective Therapeutic Regimen Management Related to complexity of medication schedules or avoidance of triggers Related to inconsistent adherence to prescribed treatment Interventions The school nurse will ensure the student takes prescribed medications (e.g., beta-blockers) at school if required. The school nurse will monitor for side effects of medications and report concerns to the healthcare provider. The school nurse will communicate with caregivers about the importance of adherence to treatment plans. The school nurse will collaborate with teachers to minimize stress and accommodate medication schedules. Expected Outcomes The student will adhere to the prescribed medication regimen without interruption. The student and caregivers will demonstrate understanding of the importance of treatment adherence. Nursing Diagnosis: Risk for Social Isolation Related to restrictions on physical activities or participation in sports Related to fear of disclosing the condition to peers Interventions The school nurse will foster an inclusive environment by encouraging participation in safe group activities. The school nurse will educate peers about medical diversity (with the family’s consent) to reduce stigma. The school nurse will collaborate with teachers to ensure accommodations for the student without drawing attention to limitations. The school nurse will provide emotional support and encourage the student to build friendships in low-stress environments. Expected Outcomes The student will actively engage in social and school activities. The student will report feeling included and supported by peers and staff. Nursing Diagnosis: Risk for Anxiety Related to fear of sudden cardiac events or arrhythmias Related to stress from activity restrictions or medical dependence Interventions The school nurse will teach relaxation techniques, such as deep breathing or mindfulness, to reduce stress. The school nurse will provide reassurance and clear explanations about the condition and safety measures in place. The school nurse will refer to a counselor or psychologist if anxiety significantly impacts the student’s quality of life. The school nurse will communicate regularly with caregivers to identify and address sources of anxiety. Expected Outcomes The student will demonstrate reduced anxiety and improved emotional well-being. The student will use learned coping techniques to manage fears effectively. Nursing Diagnosis: Risk for Noncompliance Related to resistance to activity restrictions Related to fear of social stigma related to condition management Interventions The school nurse will educate the student on the importance of adhering to activity restrictions and treatment plans. The school nurse will work with the student to identify activities they enjoy that are within safe limits. The school nurse will provide positive reinforcement for adherence to prescribed safety measures. The school nurse will address barriers to compliance, such as embarrassment or fear, through open communication. Expected Outcomes The student will adhere to activity restrictions and treatment recommendations. The student will demonstrate understanding of the importance of safety measures. Would you like to add another nursing diagnosis? Yes No Nursing DiagnosisNursing DiagnosisAdd your own nursing diagnosisInterventionsAdd your own nursing interventionsExpected OutcomesAdd your own expected outcomesNursing Diagnosis Add RemoveInterventions Add RemoveExpected Outcomes Add Remove Add More EVALUATIONNOTESIHP Developed ByName First Last Title Date Month Day Year Please enter a valid date. Do you want to include physician and parent signature lines? Yes Download IHP Clicking this button will download this IHP to your computer and return you to the blank IHP. Return Clicking this button will return you to the IHP to make changes.
