DYSAUTONOMIA 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: Risk for Syncope Related to abnormal autonomic regulation of blood pressure and heart rate. Related to prolonged standing or sudden changes in posture. Interventions The school nurse will educate the student on recognizing pre-syncopal symptoms and safe postural transitions. The school nurse will ensure the student has access to salty snacks or additional fluids if recommended by their healthcare provider. The school nurse will develop a care plan that includes a protocol for responding to syncope, including when to seek further medical evaluation. Expected Outcomes The student will avoid or effectively manage episodes of syncope. The student will demonstrate understanding and adherence to preventive strategies. Nursing Diagnosis: Impaired Physical Mobility Related to fatigue and weakness associated with dysautonomia. Related to dizziness or instability when standing or walking. Interventions The school nurse will coordinate with the physical education teacher to modify physical activity as needed. The school nurse will allow use of elevators and provide additional time for transitions between classes. The school nurse will provide a safe place for the student to rest when symptoms exacerbate. Expected Outcomes The student will participate in school activities within their physical limitations. The student will navigate the school environment safely and with minimal discomfort. Nursing Diagnosis: Activity Intolerance Related to chronic fatigue due to dysregulation of the autonomic nervous system. Related to decreased stamina and endurance. Interventions The school nurse will work with the student to tailor a balanced schedule that allows for periods of rest. The school nurse will educate teachers and staff about the student’s energy limitations. The school nurse will monitor and adjust the student’s daily activity level based on their reported and observed tolerance. Expected Outcomes The student will maintain optimal engagement in school activities without exacerbating symptoms. The student will recognize their limits and effectively use strategies to manage fatigue. Nursing Diagnosis: Disturbed Sleep Pattern Related to symptoms of dysautonomia interfering with the ability to fall asleep or stay asleep. Related to effects of medications. Interventions The school nurse will provide guidance on sleep hygiene practices. The school nurse will discuss with parents and possibly healthcare providers the impact of symptoms or medications on sleep. The school nurse will allow for a flexible school schedule to accommodate periods of poor sleep. Expected Outcomes The student will report improved quality and quantity of sleep. The student will demonstrate increased alertness and participation during school hours. Nursing Diagnosis: Anxiety Related to stress associated with managing a chronic illness. Related to concerns about having symptoms while at school. Interventions The school nurse will provide a supportive environment where the student feels safe discussing their feelings and symptoms. The school nurse will facilitate access to mental health resources, such as counseling. The school nurse will educate the student and staff on the nature of dysautonomia to foster understanding and reduce stigma. Expected Outcomes The student will express feelings of decreased anxiety related to their condition. The student will utilize coping strategies to manage stress effectively. Nursing Diagnosis: Risk for Ineffective Health Maintenance Related to lack of understanding about the nature of dysautonomia and its management. Related to difficulty identifying and managing triggers that exacerbate symptoms. Interventions The school nurse will provide education on dysautonomia, including potential triggers and effective management strategies. The school nurse will collaborate with the student, family, and healthcare providers to develop a comprehensive health management plan. The school nurse will regularly review and update the plan based on the student’s condition and needs. Expected Outcomes The student and family will demonstrate knowledge of dysautonomia and engagement in effective management practices. The student will maintain their health to the best of their ability, with minimal interruptions to their education. 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.
