Allergy and Anaphylaxis Action Plan and Medication Orders Student s Name: D.O.B. Grade: School: Teacher: ALLERGY TO: Place child s photo here To be completed by healthcare provider History: Asthma: YES (Higher risk for severe reaction) NO STEP 1: TREATMENT Any SEVERE SYMPTOMS after suspected or known ingestion: One or more of the following: LUNG: Short of breath, wheeze, repetitive cough HEART: Pale, blue, faint, weak pulse, dizzy, confused THROAT: Tight, hoarse, trouble breathing/swallowing MOUTH: Obstructive swelling (tongue and/or lips) SKIN: Many hives over body Or combination of symptoms from different body areas: SKIN: Hives, itchy rashes, swelling (e.g., eyes, lips) GUT: Vomiting, crampy pain MILD SYMPTOMS ONLY: MOUTH: Itchy mouth SKIN: A few hives around mouth/face, mild itch GUT: Mild nausea/discomfort 1. INJECT EPINEPHRINE IMMEDIATELY 2. Call 911 3. Begin monitoring (see box below) 4. Give additional medications:* Antihistamine Inhaler (quick relief) if asthma *Antihistamine & quick relief inhalers are not to be depended upon to treat a severe reaction (anaphylaxis). USE EPINEPHRINE 1. GIVE ANTIHISTAMINE 2. Stay with student; alert healthcare professionals and parent 3. If symptoms progress (see above), USE EPINEPHRINE 4. Begin monitoring DOSAGE Epinephrine: inject intramuscularly using autoinjector (check one): 0.3 mg 0.15 mg Administer 2 nd dose if symptoms do not improve in minutes Antihistamine: (brand and dose) If Asthmatic: (brand and dose) Student has been instructed and is capable of carrying and self-administering own medication. Yes No Provider (print) Phone Number: Provider s Signature: Date: If this condition warrants meal accommodations from food service, please complete the medical statement for dietary disability STEP 2: EMERGENCY CALLS 1. If epinephrine given, call 911. State that an allergic reaction has been treated and additional epinephrine, oxygen, or other medications may be needed. 2. Parent: Phone Number: 3. Emergency contacts: Name/Relationship Phone Number(s) a. 1) 2) b. 1) 2) EVEN IF PARENT/GUARDIAN CANNOT BE REACHED; DO NOT HESITATE TO ADMINISTER EMERGENCY MEDICATIONS I give permission for school personnel to share this information, follow this plan, administer medication and care for my child and, if necessary, contact our health care provider. I assume full responsibility for providing the school with prescribed medication and delivery/monitoring devices. I approve this Severe Allergy Care Plan for my child. Parent/Guardian s Signature: School Nurse: Date: Date:
Student Name: DOB: TRAINED/DELEGATED STAFF MEMBERS 1. Room 2. Room 3. Room 4. Room 5. Room Self-carry contract on file. Yes No Medication located in: EpiPen and EpiPen Jr. Expiration date: Pull off blue activation cap. Auvi-Q 0.3 mg. and 0.15 mg Expiration date: Pull the Auvi-Q from the outer case. Pull off Red safety guard. Place black end against the middle of the outer thigh (through clothing, if needed), then press firmly, and hold in place for 5 seconds. Hold orange tip near outer thigh (through clothing, if needed) Swing and jab firmly into outer thigh until Auto Injector mechanism functions. Hold in place and count to 10. Remove the EpiPen unit and massage the injection area for 10 seconds. Once epinephrine is used, call 911. Student should remain lying down or in a comfortable position. Additional information: C.R.S. 22-2-135(3)(b) 2/2013
COLORADO SCHOOL ASTHMA CARE PLAN & MEDICATION ORDERS Name: Birth date: Teacher: Grade: Parent/Guardian: Cell Phone: Home Phone: Work Phone: Other Contact: Phone: Preferred Hospital: Triggers: Weather (cold air, wind) Illness Exercise Smoke Dog/Cat Dust Mold Pollen Other: Location of medication: school office student possession at all times other location (list) GREEN ZONE: PRETREATMENT STEPS FOR EXERCISE (Health provider please complete section) Give 2 puffs of quick relief med (name) 15 minutes before activity (Circle indication: Phys Ed class, exercise/sports, recess) Explanation: Repeat in 4 hours if needed for additional or ongoing physical activity YELLOW ZONE: SICK UNCONTROLLED ASTHMA (Health provider complete dosing for quick relief med) IF YOU SEE THIS: DO THIS: Difficulty breathing Wheezing Frequent cough Complains of chest tightness Unable to tolerate regular activities but still talking in complete sentences Other: Stop physical activity Give quick relief med (name): If no improvement in 10-15 minutes, repeat use of rescue med: If student s symptoms do not improve or worsen, call 911 Stay with student and maintain sitting position Call parents/guardians and school nurse Student may resume normal activities once feeling better If there is no quick relief inhaler at school: Call parents/guardians to pick up student and/or bring inhaler/ medications to school Inform them that if they cannot get to school, 911 may be called RED ZONE: EMERGENCY SITUATION (Health provider complete dosing for quick relief med) IF YOU SEE THIS: Coughs constantly Struggles or gasps for breath Trouble talking (can speak only 3-5 words) Skin of chest and/or neck pull in with breathing Lips or fingernails are gray or blue Level of consciousness DO THIS IMMEDIATELY: Photo of child Give quick relief med (name): Repeat quick relief med if student not improving in 10-15 minutes Refer to anaphylaxis plan if student has life threatening allergy. Call 911 Inform attendant the reason for the call is asthma Call parents/guardians and school nurse Encourage student to take slower deeper breaths Stay with student and remain calm School personnel should not drive student to hospital INSTRUCTIONS for QUICK RELIEF INHALER USE: (HEALTH PROVIDER: PLEASE CHECK APPROPRIATE BOX(ES) Student understands the proper use of his/her asthma medications, and in my opinion, can carry and use his/her inhaler at school independently Student is to notify his/her designated school health officials after using inhaler. Student needs supervision or assistance to use his/her inhaler. Student has life threatening allergy, refer to anaphylaxis plan. HEALTH CARE PROVIDER SIGNATURE PLEASE PRINT PROVIDER S NAME DATE I give permission for school personnel to share this information, follow this plan, administer medication and care for my child and, if necessary, contact our physician. I assume full responsibility for providing the school with prescribed medication and delivery/monitoring devices. I approve this Asthma Care Plan for my child. PARENT SIGNATURE DATE 504 Plan or IEP School Nurse Signature DATE Copies of plan provided to: Teachers Phys Ed/Coach Principal Main Office Bus Driver Other CDE Regional Nurse Specialists (http://www.cde.state.co.us/healthandwellness/snh_nursing-asthma.htm ) June 2011
Cherry Creek School District #5 School: Fax #: PERMISSION TO GIVE PRESCRIPTION/HOMEOPATHIC MEDICATION AT SCHOOL The school nurse is required by Colorado State Law to have this form signed by the parents and the Health Care Provider of a student before prescription medication can be administered at school. For safety reasons, parents are requested to bring the medication directly to the nurse. If medication cannot be delivered to the clinic by the parent/guardian, please contact the health clinic to make other arrangements. Prescription meds must be in a pharmacy-labeled container that includes the child s name, medication, dosage, the prescriber s name and directions for administration. Some homeopathic preparations may require a review from the Cherry Creek School District Medical Advisory Board. New forms must be completed with any changes in medication, dose or time to be given. The parent agrees to pick up expired or unused medication within one week of notification or it will be destroyed. To be completed by Licensed Health Care Provider with prescriptive authority: Student s Name: Date of Birth: Medication: Dosage: Route: To be given at the following time(s): Special Instructions: Purpose of medication: Side effects that need to be reported:, including any adverse reaction. Starting Date: Ending Date: (Signature of Health Care Provider with Prescriptive Authority) (License Number) (Print name of Health Care Provider with Prescriptive Authority) (Phone) (Fax) ATTENTION PRESCRIBERS: IF THIS Rx IS FOR A RESCUE INHALER OR EPI-PEN: This student has been instructed by the healthcare provider in the proper use of this medication and is capable of carrying and self-administering this medication. (Signature of Health Care Provider) By signing this document, I give permission for the nurse or nurse designee to administer the medication as prescribed. Should the nurse have any concerns about this order, I give my permission for this Health Care Provider to share information about this medication s administration with the Registered Nurse. (Parent/Guardian Signature) (Phone) (Date) RV 04-10 This consent must be resubmitted at the beginning of every school year.
Seizure Action Plan Effective Date This student is being treated for a seizure disorder. The information below should assist you if a seizure occurs during school hours. Student s Name Date of Birth Parent/Guardian Phone Cell Other Emergency Contact Phone Cell Treating Physician Phone Significant Medical History Seizure Information Seizure Type Length Frequency Description Seizure triggers or warning signs: Student s response after a seizure: Basic First Aid: Care & Comfort Please describe basic first aid procedures: Does student need to leave the classroom after a seizure? Yes No If YES, describe process for returning student to classroom: Emergency Response A seizure emergency for this student is defined as: Seizure Emergency Protocol (Check all that apply and clarify below) Contact school nurse at Call 911 for transport to Notify parent or emergency contact Administer emergency medications as indicated below Notify doctor Other Treatment Protocol During School Hours (include daily and emergency medications) Basic Seizure First Aid Stay calm & track time Keep child safe Do not restrain Do not put anything in mouth Stay with child until fully conscious Record seizure in log For tonic-clonic seizure: Protect head Keep airway open/watch breathing Turn child on side A seizure is generally considered an emergency when: Convulsive (tonic-clonic) seizure lasts longer than 5 minutes Student has repeated seizures without regaining consciousness Student is injured or has diabetes Student has a first-time seizure Student has breathing difficulties Student has a seizure in water Emerg. Dosage & Med. Medication Time of Day Given Common Side Effects & Special Instructions Does student have a Vagus Nerve Stimulator? Yes No If YES, describe magnet use: Special Considerations and Precautions (regarding school activities, sports, trips, etc.) Describe any special considerations or precautions: Physician Signature Date Parent/Guardian Signature Date DPC772 Copyright 2008 Epilepsy Foundation of America, Inc.