CONCUSSION 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 post-concussive headaches Interventions The school nurse will obtain any restrictions and orders from parent and physician The school nurse will assess need for and administer medication if ordered and as directed The school nurse will provide a quiet, dark place for rest at headache onset. Quiet music might be beneficial. Use of electronic devices should not be permitted. The school nurse will notify student's teachers of concussion to allow free access to nurse as needed, and to leave classroom if excessively noisy The school nurse will discuss treatment plan with student and evaluate compliance at home The school nurse will encourage adequate sleep, limited electronics, adequate hydration, and scheduled rest periods/breaks as needed The school nurse will allow for lunch in a quiet environment with a friend if needed The school nurse will assist teachers with classroom and academic accommodations as needed and/or as requested by physician The school nurse will consider referring to 504 Plan for prolonged post-concussive syndrome and prolonged need for accommodations Expected Outcomes The student will follow concussion medical plan from physician The student will have fewer headaches at school demonstrated by fewer nurse office visits The student will resume normal, daily school activities without developing headaches Nursing Diagnosis: Decreased activity intolerance Related to fatigue and headaches from concussion Interventions The school nurse will obtain any restrictions and orders from parent and physician The school nurse will encourage adequate sleep, limited electronics, adequate hydration and scheduled rest periods/breaks as needed The school nurse will notify teachers of student with concussion to allow free access to nurse as needed, and to leave classroom if excessively noisy The school nurse will provide a quiet, dark place for rest at headache onset. Quiet music permitted; no electronics activity. The school nurse will follow activity restrictions as ordered by physician and increase activity through slow progression as indicated by physician The school nurse will allow student to self-regulate activity level when working through increased activity progression The school nurse will follow school's return-to-play policies The school nurse will consider referring to 504 plan for prolonged post-concussive syndrome and prolonged need for accommodations Expected Outcomes The student will participate in school activities at their level of tolerance to activity The student will demonstrate improved activity tolerance The student will resume and tolerate normal school day activities Nursing Diagnosis: Risk for disturbed thought processes Related to concussion Interventions The school nurse will obtain any restrictions and orders from parent and physician The school nurse will encourage adequate sleep, limited electronics, adequate hydration and built-in rest periods/breaks as needed The school nurse will discuss treatment plan with student and evaluate compliance at home The school nurse will notify teachers of student with concussion and share physician-requested accommodations as requested for classwork The school nurse will assist teachers with classroom and academic accommodations as needed, which may include reduced assigments, providing written notes and instructions, extra time for assigments and make-up work, no timed testing, excuse non-essential assignments, avoid excessive screen time for assignments and provide alternative for assignment The school nurse will consider referring to 504 Plan for prolonged post-concussive syndrome and prolonged need for accommodations Expected Outcomes The student will use positive coping skills to decrease frustration and anxiety The student will verbalize positive steps and progress during recovery process Nursing Diagnosis: Anxiety Related to decreased activity tolerance and progression of healing from concussion Interventions The school nurse will allow student to verbalize feelings about current limitations and healing process The school nurse will support student and provide encouragement about their progress, improvement, and healing The school nurse will refer to counseling if observing excessive anxiety, frustration or depression and needing help developing coping skills Expected Outcomes The student and family will be supported and provided information during the healing process The student and family will feel heard when expressing their concerns and questions The student and family will follow the physician's management plan Nursing Diagnosis: Deficient knowledge Related to concussions and concussion management Interventions The school nurse will educate student and family about concussion and concussion management The school nurse will assist student and family in following physician's management plan, and stress importance of following plan for healing The school nurse will continue to assess and reinforce education about concussions and mangement of them, especially if there are prolonged, post-concussive issues The school nurse will be available and listen to the student's and parent's questions and concerns. Expected Outcomes The student and family will be supported and provided information during the healing process The student and family will feel heard when expressing their concerns and questions The student and family will follow the physician's management plan 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.
