ACTIVITY INTOLERANCE 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: Activity Intolerance related to Physical Injury Related to acute pain or discomfort associated with the injury. Related to reduced strength, endurance, or mobility due to healing or rehabilitation needs. Related to fear of reinjury or exacerbating the condition. Interventions The school nurse will assess the student’s physical limitations and tolerance for various activities, documenting any signs of fatigue or discomfort. The school nurse will develop an individualized activity plan in collaboration with healthcare providers, teachers, and physical education staff. The school nurse will encourage participation in light, non-strenuous activities that align with the student’s capabilities. The school nurse will provide rest periods throughout the day to prevent fatigue and overexertion. The school nurse will monitor for any changes in the student’s condition, such as increased pain, swelling, or difficulty moving. Expected Outcomes The student will engage in modified activities without exacerbating their condition. The student will report reduced fatigue and improved comfort during school hours. The student will demonstrate adherence to activity limitations and safety precautions. Nursing Diagnosis: Risk for Injury related to Reduced Mobility or Impaired Balance Related to use of assistive devices (e.g., crutches, splints) that may impact balance or stability. Related to limited weight-bearing capacity on the injured area. Related to difficulty navigating the school environment due to mobility challenges. Interventions The school nurse will assess the school environment for potential hazards (e.g., uneven surfaces, crowded hallways) and make adjustments as needed. The school nurse will ensure the student has access to assistive devices and knows how to use them correctly. The school nurse will collaborate with school staff to provide classroom seating or workstation accommodations near accessible routes. The school nurse will educate the student on strategies to prevent falls or injuries, such as moving slowly, avoiding high-traffic areas, and using handrails. The school nurse will monitor the student’s progress and address any issues with mobility or equipment. Expected Outcomes The student will navigate the school environment safely with no additional injuries. The student will demonstrate proper use of assistive devices and adherence to safety precautions. School staff will report a safe and supportive environment for the student’s mobility needs. Nursing Diagnosis: Impaired Physical Mobility related to Activity Restrictions Related to immobilization of the injured body part (e.g., cast, brace) limiting range of motion. Related to pain or swelling that hinders movement. Related to the need for partial or complete weight-bearing restrictions. Interventions The school nurse will encourage gentle movement or stretching exercises as allowed by the healthcare provider to prevent stiffness and promote circulation. The school nurse will coordinate with teachers to minimize unnecessary movement between classrooms by modifying the student’s schedule or allowing remote participation. The school nurse will provide ergonomic accommodations, such as supportive seating, to improve comfort and reduce strain. The school nurse will offer frequent rest breaks to reduce discomfort and promote recovery. The school nurse will monitor the student’s physical progress and communicate with healthcare providers about any changes or concerns. Expected Outcomes The student will experience improved comfort and reduced stiffness during school hours. The student will demonstrate safe mobility within the scope of their restrictions. The student’s condition will show no signs of worsening due to school activities. Nursing Diagnosis: Risk for Social Isolation related to Limited Participation in Activities Related to inability to participate in physical education or recess activities with peers. Related to feelings of exclusion or self-consciousness about the injury or assistive devices. Related to reduced opportunities for social interaction due to activity limitations. Interventions The school nurse will encourage peer support by fostering inclusion in group activities that do not require physical exertion. The school nurse will collaborate with teachers to involve the student in alternative classroom or group tasks to maintain engagement. The school nurse will offer emotional support and reassurance to reduce feelings of isolation or self-consciousness. The school nurse will arrange for social opportunities during non-physical activities, such as group discussions or collaborative projects. The school nurse will educate peers about the importance of supporting and including classmates with temporary limitations. Expected Outcomes The student will report feeling included and supported by peers and staff. The student will participate in alternative activities that foster social interaction. The student will demonstrate a positive attitude toward their recovery and school experience. Nursing Diagnosis: Acute Pain related to Injury and Healing Process Related to pain from the injured area or associated swelling and inflammation. Related to discomfort from immobilization devices such as casts, splints, or braces. Related to physical movement exacerbating pain symptoms. Interventions The school nurse will assess the student’s pain level regularly using an age-appropriate pain scale. The school nurse will encourage relaxation techniques, such as deep breathing or distraction, to help manage pain. The school nurse will collaborate with the student’s healthcare provider to ensure pain management medications, if prescribed, are administered appropriately. The school nurse will adjust the school day schedule as needed to allow for rest periods to minimize discomfort. The school nurse will provide physical comfort measures, such as pillows for support or elevating the injured limb to reduce swelling. Expected Outcomes The student will report manageable pain levels during school hours. The student will demonstrate the use of pain management techniques to improve comfort. The student will participate in school activities within the limits of their pain tolerance. Nursing Diagnosis: Deficient Knowledge related to Activity Restrictions and Recovery Process Related to limited understanding of the need for activity restrictions to promote healing. Related to lack of knowledge about safe practices and accommodations to prevent reinjury. Related to uncertainty about the importance of adhering to rehabilitation guidelines. Interventions The school nurse will educate the student and caregivers on the importance of following activity restrictions to ensure proper healing. The school nurse will provide clear instructions on safe practices, such as using assistive devices correctly and avoiding overexertion. The school nurse will create a written plan for activity modifications and distribute it to the student, caregivers, and school staff. The school nurse will reinforce the importance of attending follow-up medical appointments and adhering to prescribed rehabilitation exercises. The school nurse will monitor the student’s understanding and compliance with activity restrictions, offering reminders or corrections as needed. Expected Outcomes The student and caregivers will demonstrate understanding of activity restrictions and safety measures. The student will adhere to the activity plan, avoiding behaviors that could delay healing or cause reinjury. The student will report confidence in managing their recovery process at school. 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.
