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Microsoft word - superchick 2010 severe allergic reaction plan.doc

SEVERE ALLERGIC REACTION/504 PLAN & MEDICATION ORDERS
Birthdate:
Allergy History:
Skin testing indicates allergy Date of Last Reaction:
Other Allergies:
Student has Asthma (increased risk factor for severe reaction)
Anaphylaxis (Severe allergic reaction) is an excessive reaction by the body to combat a foreign substance that has been eaten, injected, inhaled
or absorbed through the skin. It is an intense and life- threatening medical emergency. Do not hesitate to give Epi auto-injector and call 911.
USUAL SYMPTOMS of an allergic reaction:
MOUTH--Itching, tingling, or swelling of the lips, tongue, or mouth SKIN--Hives, itchy rash, and/or swelling about the face or extremities THROAT--Sense of tightness in the throat, hoarseness and hacking cough GUT--Nausea, stomach ache/abdominal cramps, vomiting and/or diarrhea LUNG--Shortness of breath, repetitive coughing, and/or wheezing HEART --“Thready” pulse, “passing out”, fainting, blueness, pale GENERAL--Panic, sudden fatigue, chills, fear of impending doom
This Section To Be Completed By A Licensed Healthcare Provider (LHP):
If a student has symptoms or you suspect exposure (is stung, eats food he/she is allergic to, or exposed to something allergic to): 1. Give Epi auto-injector
May repeat Epi auto-injector (if available) in 10-15 minutes if symptoms are not relieved or symptoms return and EMS
has not arrived.
Document time medications were given below and alert EMS when they arrive.
2. Stay with student.
3. CALL 911 – Advise EMS that student has been given Epinephrine
4. Notify parents and school nurse.
5. After Epi auto-injection given, give Benadryl® or antihistamine____ ___(ml/mg/cc)
6. If student has history of Asthma and is having wheezing, shortness of breath, chest tightness with allergic reaction,
After Epi auto-injection and antihistamine, may give: Albuterol 2 puffs (Pro-air®, Ventolin HFA®, Proventil®) Albuterol/ Levalbuterol unit dose SVN (per nebulizer) 7. A Student given an Epi auto-injector must be monitored by medical personnel or a parent & may NOT remain at school.
SIDE EFFECTS of medication(s):
Epi auto-injector: increased heart rate,__ _____
Antihistamine: sleepy, _________________
Albuterol/Levalbuterol: increased heart rate, shakiness, _ _________
Student may carry & self administer Epi auto-injector +/or antihistamine Student has demonstrated Epi auto-injector use in LHP’s office Student may carry & self administer Inhaler Student has demonstrated inhaler use LHP’s office PLEASE COMPLETE THIS SECTION IF THE STUDENT HAS A SEVERE FOOD ALLERGY (required by USDA) Food Guidelines
Check here if student will EAT school provided meals during the entire school year. If so, one of the following must be completed.
1. Foods to omit:__ _______________________Suggested general substitutions:__ _________________________________
2._____________Parent will review menu and send cold lunches from home when menu contains foods the student is allergic to.
Note: Meals from home provide the safest food option at school.
Student:__
Care Plan for Severe Allergy – Part 2 – Parent
Brief Medical History__ __
Food Allergy Accommodations
• Foods and alternative snacks will be approved or provided by parent/guardian.
• Parent/guardian should be notified of any planned parties as early as possible. • Classroom projects should be reviewed by the teaching staff to avoid specified allergens. • Student is responsible for making his/her own food decisions. Bus Concerns –Transportation should be alerted to student’s allergy.
• This student carries Epi auto-injector on the bus?
• Student will sit at front of the bus? Field Trip Procedures – Epi auto-injector must accompany student during any off campus activities.
• The student must remain with the teacher or parent/guardian during the entire field trip?
• Staff members on trip must be trained regarding Epi auto-injector use and this health care plan (plan must be taken). EMERGENCY CONTACTS

ADDITIONAL EMERGENCY CONTACTS
1.
My student may carry and is trained to self-administer his/her own Epi auto-injector: My student may carry and use his/her asthma inhaler:  I request this medication to be given as ordered by the licensed health professional (LHP) (i.e.: doctor, nurse practitioner, PAC).  I give health services staff permission to communicate with the LHP/medical office staff about his medication.  I understand that any medication will not necessarily be given by a school nurse but may be given by trained and supervised school staff. I release school staff from any liability in the administration of this medication at school.  Medical/medication information may be shared with school staff working with my child and 911 staff, if they are called.  All medication supplied must come in its originally provided container with instructions as noted above by the licensed health professional.  Student is encouraged to wear a medical ID bracelet identifying the medical condition.  I request and authorize my child to carry and/or self-administer their medication.  This permission to possess and self-administer any medication may be revoked by the principal/school nurse if it is determined that the student cannot safely and effectively self-administer. Parent/Guardian Signature
For District Nurse’s Use Only
Student has demonstrated to the nurse, the skill necessary to use the medication and any device necessary to self-administer the medication School Nurse Signature
A copy of the Health Care Plan will be kept in the substitute folder and given to all staff members who are involved with the student. Rev 4/23/10

Source: http://www.reardan.net/cms/lib04/WA01000665/Centricity/Domain/20/Severe%20Allergic%20Reaction%20504%20Plan%20and%20Medication%20Orders.pdf

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