Emergency Allergy Health Care Plan

Student 	D.O.B. 	ID 	_
ALLERGY TO: 	_
Asthmatic	Yes•D	_No _□	•High risk for severe reaction
STEP 1: TREATMENT	♦

GIVE the CHECKED MEDICATION as indicated by situation (to be determined by physician):
If a food allergen has been ingested or student has been stung, but no symptoms	0	EpiPen
Mouth	Itching, tingling, or swelling of lips, tongue, mouth  ---	D EpiPen
Skin	Hives, itchy rash, swelling of face or extremities	_---	_D _EpiPen
Gut	Nausea} abdominal cramps, vomiting, diarrhea	0	EpiPen

D Benadryl D Benadryl D Benadryl D Benadryl

Throat t
Lung t
Heart t

Tightening of throat, hoarseness, hacking cough      _---	_D _EpiPen Shortness of breath, repetitive coughing, wheezing ---	D EpiPen Thready pulse, low blood pressure, fainting, pale, blueness - D EpiPen

D Benadryl D Benadryl D Benadryl

^Other	 	-	D EpiPen
If reaction is progressing (several of the above areas affected), give ---	D EpiPen
The severity of symptoms can quickly change. f Potentially life-threatening.
MEDICATION DOSAGE (to be completed by physician)

D Benadryl
D Benadryl

^Epinepht·ine: ^inject ^intramuscularly ^(circle ^one)   ^EpiPen	EpiPen Jr.

Benadryl or other antihistamine: give	­
Medication/dose/route
Other medication: give	Medication/dose/route
STEP  2: EMERGENCY CALLS	♦
Call 911 (State that an allergic reaction has been treated, and additional epinephrine may be needed.)
Call: Molher/guardian 	(H) 	(W). 	(C)  	

Father/guardian  	)(H
Alternate emergency contacts:	Name/Relationship

(W).

Phone numbers

{C)  	

(If parent cannot be located)	a.--------------------------------------
b. 	_
Call: Dr. 	al  	

--------ccc--77-c--=--,	/ 	_
Physician's Signature	Date
(A Medication A11thorization Form must also be completed)

EPIPEN® DIRECTIONS
Pull off gray activation cap.
Hold black tip near outer thigh (always apply to thigh).
Swing and jab fimlly into outer thigh.
Hold in place and count lo ten.
Remove EpiPen (give used unit to a paramedic).
Massage the injection area for 10 seconds.

(See reverse or page 2 for additional parental information)

_     		/--cc-,--

□	 	

ParenUGuardian's Signature	Date

/1-------1

IF:	.,=t:.	-	i	ta 

Other concerns/Information for Parents and Teachers:

Anaphylaxis is a rare, life-threatening allergy to certain substances such as foods, bee stings, chemicals and medications. It occurs rapidly and can close off the breathing passages. If instant treatment does not occur, it can be fatal. It is important to note that there is little downside to giving epinephrine if it is not needed; however, delaying treatment can result in tragedy.

II is the parent's responsibility to notify Health Services of their student's involvement in any extra­ curricular activities. Health Services will then provide a copy of the health plan to coaches, club sponsors, etc.

Students must carry an extra EpiPen and Benadryl (if ordered by physician) to all extracurricular activities such at athletic practices and games, fieldtrips and club events. Students are responsible to inform their coach, field trip sponsor or club sponsor of the Benadryl and EpiPen's exact location i.e., sport bag on the field, fanny pack, etc.

Prior to any off-campus activity, a parent must give advance notice to the field trip sponsor or coach regarding their student's special health needs. Other certificated school personnel may volunteer to assist in medication administration and will be given instructions by the nurse. If no volunteer is available, the parent/guardian must make other arrangements for administration.

Teachers, coaches, and field trip sponsors will review the Emergency Allergy Health Care Plan. If a teacher, coach or field trip sponsor would like to learn how to properly use an EpiPen in order to assist this student, please contact Health Services.

PE Teachers: If a student has a bee sting allergy, please provide an alternate PE location away from bees.

A teacher's copy of this plan must accompany the student on all off-campus activities

Teachers will place a copy of this plan in their personal file and another copy in their substitute information file along with seating charts, emergency lesson plans, etc.

^Parent ^Signature	Date

School Nurse Signature	^Date