LYME DISEASE 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? Yes No Teacher Name Homeroom Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Emergency Contact List is attached to IHP. 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: Acute Pain Related to inflammation of joints (arthritis) Related to neurological symptoms, such as headaches or muscle aches Interventions The school nurse will monitor the student for signs of pain and provide a quiet space for rest as needed. The school nurse will collaborate with caregivers to ensure adherence to prescribed pain management strategies, such as NSAIDs. The school nurse will encourage gentle stretching or light activity to reduce stiffness. The school nurse will communicate with teachers about modifications for physical activities, if needed. Expected Outcomes The student will report reduced pain during school hours. The student will participate in school activities with minimal discomfort. Nursing Diagnosis: Risk for Activity Intolerance Related to fatigue or muscle weakness due to Lyme disease Related to joint pain or swelling Interventions The school nurse will allow rest breaks during the school day to manage fatigue. The school nurse will collaborate with physical education teachers to adjust physical activity levels. The school nurse will encourage the student to pace themselves during academic and physical tasks. The school nurse will monitor for signs of overexertion and adjust the student's schedule if necessary. Expected Outcomes The student will tolerate academic and physical activities without significant fatigue or distress. The student will report feeling supported in managing their energy levels. Nursing Diagnosis: Fatigue Related to chronic inflammation from Lyme disease Related to disrupted sleep due to pain or discomfort Interventions The school nurse will educate the student and caregivers about the importance of maintaining a consistent sleep schedule. The school nurse will provide opportunities for rest during the school day as needed. The school nurse will encourage healthy snacks and hydration to support energy levels. The school nurse will communicate with caregivers about managing fatigue and its impact on school performance. Expected Outcomes The student will report improved energy levels during school hours. The student will actively participate in classroom and extracurricular activities. Nursing Diagnosis: Impaired Memory Related to cognitive effects of Lyme disease, such as brain fog or difficulty concentrating Related to fatigue interfering with focus and learning Interventions The school nurse will collaborate with teachers to implement accommodations, such as extended time for assignments or testing. The school nurse will encourage the use of memory aids, such as planners or visual reminders. The school nurse will provide a quiet and distraction-free environment for tasks that require concentration. The school nurse and counselors will monitor academic performance and refer to specialists if significant difficulties persist. Expected Outcomes The student will demonstrate improved focus and memory with appropriate accommodations. The student will meet academic goals as outlined in an individualized education plan (IEP) if applicable. Nursing Diagnosis: Risk for Social Isolation Related to absence from school due to illness Related to fatigue or pain limiting participation in social activities Interventions The school nurse will foster opportunities for the student to engage in low-energy social activities with peers. The school nurse will educate peers about Lyme disease to promote understanding and reduce stigma (with the family’s consent). The school nurse will work with teachers and school staff to ensure the student feels included in classroom and extracurricular activities. The school nurse will encourage the student to maintain friendships through virtual or in-person interactions when possible. Expected Outcomes The student will actively participate in social and school activities. The student will report feeling connected to peers and supported by staff. Nursing Diagnosis: Deficient Knowledge Related to lack of understanding about Lyme disease, its symptoms, and management Related to uncertainty about long-term effects and treatment adherence Interventions The school nurse will provide age-appropriate education to the student and caregivers about Lyme disease and its management. The school nurse will teach the importance of completing prescribed antibiotic therapy and recognizing signs of recurrence or complications. The school nurse will share resources and information about lifestyle adjustments to support recovery. The school nurse will educate school staff on Lyme disease symptoms and potential accommodations for the student. Expected Outcomes The student and caregivers will demonstrate understanding of Lyme disease and its management. School staff will implement necessary accommodations to support the student’s success. Nursing Diagnosis: Risk for Impaired Skin Integrity Related to potential for re-exposure to tick bites during outdoor activities Related to skin irritation from potential rashes or insect bites Interventions The school nurse will educate the student and caregivers about tick prevention strategies, such as wearing protective clothing and using insect repellent. The school nurse will teach proper tick removal techniques and the importance of prompt action if a tick is found. The school nurse will monitor the student’s skin for any signs of irritation or rashes, particularly erythema migrans (bull’s-eye rash). The school nurse will collaborate with physical education staff to limit exposure during outdoor activities. Expected Outcomes The student will demonstrate understanding of tick prevention measures. The student will remain free from new tick bites or related skin complications. Nursing Diagnosis: Risk for Noncompliance Related to side effects of medications (e.g., antibiotics) Related to misunderstanding of the importance of completing treatment Interventions The school nurse will educate the student and caregivers about the importance of completing the full course of antibiotics to prevent complications. The school nurse will address barriers to compliance, such as medication side effects, by coordinating with the healthcare provider for adjustments if necessary. The school nurse will use reminders or visual aids to support adherence to the medication schedule. The school nurse will provide positive reinforcement for following the treatment plan. Expected Outcomes The student and caregivers will adhere to the prescribed treatment regimen. The student will show signs of recovery with no complications from incomplete treatment. 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.
