CELIAC 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: Imbalanced Nutrition: Less than Body Requirements Related to malabsorption of nutrients due to damage to the small intestine from gluten exposure Related to dietary restrictions limiting food variety or intake Related to poor appetite or reluctance to eat unfamiliar gluten-free foods Interventions The school nurse will collaborate with a dietitian to create a well-balanced, gluten-free meal plan that meets the student’s nutritional needs. The school nurse will educate the student and family about safe gluten-free food options, including reading labels and avoiding cross-contamination. The school nurse will encourage small, frequent meals and snacks to improve overall caloric and nutrient intake. The school nurse will monitor the student’s growth, weight, and overall nutritional status regularly to assess for improvement or deficiencies. Expected Outcomes The student will demonstrate understanding of gluten-free dietary requirements and consume a balanced diet. The student will achieve or maintain a healthy weight and show improved growth patterns. The student will experience reduced symptoms related to malabsorption, such as fatigue or gastrointestinal distress. Nursing Diagnosis: Risk for Imbalanced Fluid Volume Related to diarrhea due to accidental gluten ingestion or intestinal damage Related to vomiting or reduced fluid intake during episodes of gastrointestinal distress Related to dehydration from chronic gastrointestinal symptoms Interventions The school nurse will educate the student and family about recognizing symptoms of dehydration, such as dry mouth, reduced urine output, or dizziness. The school nurse will encourage the student to drink adequate fluids, especially during periods of diarrhea or vomiting. The school nurse will provide alternative hydration methods, such as oral rehydration solutions, if plain water is not well-tolerated. The school nurse will collaborate with healthcare providers to manage symptoms effectively and prevent dehydration. Expected Outcomes The student will maintain adequate hydration levels with normal urine output and no signs of dehydration. The student will report reduced gastrointestinal symptoms and better tolerance of fluids. The student’s family will verbalize understanding of hydration needs and strategies to prevent dehydration. Nursing Diagnosis: Knowledge Deficit Related to lack of understanding of the gluten-free diet and its importance Related to difficulty identifying gluten-containing foods and cross-contamination risks Related to limited awareness of resources for managing celiac disease Interventions The school nurse will provide comprehensive education about celiac disease, including its effects on the body and the necessity of strict gluten avoidance. The school nurse will teach the student and family how to read food labels, identify hidden sources of gluten, and avoid cross-contamination at home and in school. The school nurse will provide resources, such as lists of gluten-free foods, recipes, and apps, to support dietary adherence. The school nurse will collaborate with school staff to ensure gluten-free meals and snacks are available and safe for the student. Expected Outcomes The student and family will demonstrate understanding of celiac disease and effective management strategies. The student will adhere to a strict gluten-free diet with confidence in food choices. The student and family will utilize available resources to support dietary compliance and minimize gluten exposure. Nursing Diagnosis: Risk for Ineffective Coping Related to social challenges related to dietary restrictions (e.g., feeling different from peers, difficulty participating in social events involving food) Related to anxiety about accidental gluten exposure and its consequences Related to frustration or emotional distress about the lifelong nature of the condition Interventions The school nurse will provide emotional support and encourage the student to express feelings about managing celiac disease. The school nurse will collaborate with school counselors to help the student build confidence and develop strategies for explaining their dietary needs to peers. The school nurse will encourage participation in support groups or connecting with other students with similar dietary restrictions. The school nurse will teach stress management techniques, such as deep breathing or journaling, to reduce anxiety about accidental gluten exposure. Expected Outcomes The student will demonstrate improved coping skills and confidence in managing celiac disease in social settings. The student will report reduced anxiety about gluten exposure and feel more comfortable discussing dietary needs with peers. The student will actively participate in social and school activities without fear or frustration about their condition. Nursing Diagnosis: Diarrhea Related to gluten ingestion leading to inflammation and malabsorption in the small intestine Related to chronic gastrointestinal damage from untreated or poorly managed celiac disease Related to food intolerances or dietary indiscretions Interventions The school nurse will educate the student and family about avoiding gluten to prevent gastrointestinal symptoms, including hidden sources and cross-contamination. The school nurse will collaborate with school staff to ensure gluten-free options are available and that accidental ingestion is minimized. The school nurse will monitor for signs of severe diarrhea, such as dehydration or electrolyte imbalance, and intervene as necessary. The school nurse will encourage the use of symptom diaries to track and identify potential triggers or patterns. Expected Outcomes The student will report reduced episodes of diarrhea and improved gastrointestinal comfort. The student will demonstrate understanding of strategies to avoid gluten exposure and prevent symptoms. The student will maintain adequate hydration and electrolyte balance despite occasional gastrointestinal symptoms. Nursing Diagnosis: Disturbed Body Image Related to concerns about being different due to dietary restrictions Related to fear of social stigma or exclusion during meals and events Related to potential impact on self-esteem related to chronic illness management Interventions The school nurse will provide emotional support and create a safe environment for the student to discuss concerns about body image or social acceptance. The school nurse will encourage participation in activities that focus on the student’s strengths and abilities, rather than their condition or dietary needs. The school nurse will educate school staff and peers about celiac disease to reduce stigma and promote an inclusive environment. The school nurse will empower the student to advocate for their needs and confidently manage their dietary restrictions. Expected Outcomes The student will demonstrate improved self-esteem and acceptance of their dietary needs. The student will participate in social and school activities with reduced concern about being different. The student will verbalize confidence in advocating for their dietary requirements in various settings. Nursing Diagnosis: Risk for Social Isolation Related to difficulty participating in social activities involving food Related to fear of gluten exposure leading to avoidance of events or meals with peers Related to perceived stigma or exclusion due to dietary restrictions Interventions The school nurse will collaborate with school staff to ensure that the student has safe, gluten-free options available during meals and events. The school nurse will encourage the student to communicate their dietary needs with peers and participate in social activities with confidence. The school nurse will provide education to classmates and teachers about celiac disease to foster a supportive and inclusive environment. The school nurse will suggest creative ways to include the student in food-related events, such as bringing their own gluten-free treats. Expected Outcomes The student will participate actively in school and social events without fear of gluten exposure or exclusion. The student will report feeling supported and included by peers and school staff. The student will develop positive social relationships and maintain an active social life. 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? 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