VISUAL IMPAIRMENT 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: Risk for Injury Related to limited ability to navigate the environment due to visual impairment Related to difficulty detecting hazards (e.g., stairs, sharp objects, uneven surfaces) Related to inaccessible or poorly adapted school facilities Interventions The school nurse will conduct a safety assessment of the school environment to identify and address potential hazards (e.g., ensure clear pathways, install tactile markers or handrails). The school nurse will collaborate with teachers and staff to ensure accessibility modifications, such as appropriate lighting and organization of the classroom. The school nurse will educate the student on safe navigation strategies, such as using a cane or other assistive devices. The school nurse will provide guidance to peers and staff on supporting the student without limiting their independence. Expected Outcomes The student will navigate the school environment safely with minimal risk of injury. The student will demonstrate the effective use of mobility aids and adaptive strategies. The school environment will be free of hazards and accessible to the student. Nursing Diagnosis: Impaired Social Interaction Related to difficulty interpreting non-verbal cues due to limited vision Related to challenges participating in peer activities Related to potential stigma or misunderstanding from peers about visual impairment Interventions The school nurse will collaborate with school counselors to educate peers about visual impairments, fostering understanding and inclusion. The school nurse will encourage the student to participate in structured group activities that promote peer interaction. The school nurse will teach communication strategies to peers and staff to improve interactions with the student (e.g., announcing one’s presence, describing visual content verbally). The school nurse will provide emotional support and counseling to address feelings of isolation or frustration. Expected Outcomes The student will actively participate in social interactions with peers and staff. The student will report feeling included and supported in school activities. Peers will demonstrate understanding and supportive behaviors toward the student. Nursing Diagnosis: Risk for Delayed Development Related to limited access to visual learning materials Related to difficulty using traditional educational tools, such as books, computers, or whiteboards Related to need for specialized adaptations to support learning Interventions The school nurse will collaborate with teachers to provide accessible educational materials, such as braille, large-print books, or audio resources. The school nurse will ensure the availability of assistive technology, such as screen readers, magnifiers, or voice-activated devices, to facilitate learning. The school nurse will work with special education staff to develop an Individualized Education Plan (IEP) tailored to the student’s needs. The school nurse will monitor the student’s academic progress and advocate for adjustments if necessary. Expected Outcomes The student will demonstrate consistent progress in academic tasks with appropriate support and resources. The student will use assistive technology effectively to complete assignments and participate in classroom activities. The student will feel confident and capable in their academic performance. Nursing Diagnosis: Disturbed Body Image Related to social stigma or bullying related to the use of assistive devices (e.g., glasses, cane, braille devices) Related to feelings of being "different" from peers due to the visual impairment Related to low self-esteem related to challenges in appearance or functionality Interventions The school nurse will provide emotional support and counseling to address concerns about body image and self-esteem. The school nurse will foster participation in activities that highlight the student’s strengths and abilities, rather than limitations. The school nurse will collaborate with teachers and counselors to create a supportive classroom culture that promotes inclusion and acceptance. The school nurse will address bullying or teasing promptly and create a safe space for the student to express concerns. Expected Outcomes The student will verbalize positive feelings about their abilities and self-worth. The student will participate in school and social activities with confidence. The school community will foster acceptance and inclusion, reducing stigma and bullying. Nursing Diagnosis: Knowledge Deficit Related to lack of understanding of available resources, tools, and accommodations Related to limited knowledge among school staff about the student’s specific needs Related to inconsistent use of assistive devices or adaptations Interventions The school nurse will provide education to the student and family about available tools and resources for managing visual impairment, such as assistive devices and mobility training. The school nurse will offer training to teachers and staff on supporting the student’s needs, including classroom modifications and communication strategies. The school nurse will collaborate with specialists, such as orientation and mobility instructors, to ensure the student develops skills for independence. The school nurse will provide opportunities for the student to practice using assistive devices in a supportive environment. Expected Outcomes The student will demonstrate effective use of assistive devices and adaptations in the school setting. The student and family will feel confident in managing the student’s visual impairment. School staff will demonstrate knowledge of the student’s needs and implement accommodations effectively. Nursing Diagnosis: Risk for Low Self-Esteem Related to dependence on others for certain tasks Related to perceived limitations due to visual impairment Related to negative social experiences or fear of judgment Interventions The school nurse will encourage independence by teaching self-advocacy skills and promoting the use of assistive technology. The school nurse will provide opportunities for the student to participate in leadership roles or extracurricular activities that showcase their abilities. The school nurse will offer regular check-ins with the student to address any concerns about self-esteem or peer interactions. The school nurse will collaborate with school counselors to provide targeted support, such as self-esteem workshops or peer mentorship programs. Expected Outcomes The student will demonstrate increased confidence in their abilities and independence. The student will actively participate in school activities and advocate for their needs. The student will report positive feelings about their self-worth and abilities. Nursing Diagnosis: Ineffective Coping Related to frustration with challenges related to visual impairment Related to difficulty managing emotions related to social or academic struggles Related to limited coping strategies for handling stressors Interventions The school nurse will provide emotional support and a safe space for the student to express frustrations or concerns. The school nurse will teach coping strategies, such as deep breathing, problem-solving, or seeking help when needed. The school nurse will connect the student with counseling or peer support groups to share experiences and learn from others with similar challenges. The school nurse will encourage participation in activities that promote relaxation and emotional well-being. Expected Outcomes The student will demonstrate effective coping strategies to manage stress and frustration. The student will seek support when needed and report reduced emotional distress. The student will actively participate in school activities with improved resilience and confidence. 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.
