Name of Form s2

Nash-Rocky Mount Public Schools Student Health Services Hemophilia – Emergency Action Plan

Student DOB GR School YR Parent/Guardian Cell Home Work Teachers Car Bus Bus #

If this happens: Do this: Nosebleed 1. Use Universal Precautions. 2. Notify nurse and/or office. 3. Have child sit with head upright, leaning slightly forward. 4. Apply continuous pressure to the nose by pinching nose for 20 minutes. 5. Apply ice to bridge of nose while pinching. 6. Call parent/guardian if bleeding not stopped after 20 minutes 7. If bleeding stops within 20 min, still call parent to inform of bleeding. Mouth Bleed 1. Use Universal Precautions. 2. Notify nurse and/or office. 3. Apply ice, cold compress to area of injury with continuous firm pressure for 20 minutes. 4. Call parent/guardian if bleeding not stopped after 20 min of pressure. 5. If bleeding stops within 20 min, still call parent to inform of injury and to assess for need of sutures. Bleeding from cut, scrape, or laceration 1. Use Universal Precautions. 2. Notify nurse and/or office. 3. Clean wound with soap and water. 4. Apply pressure and elevate the body part until bleeding stops. Must stop within 20 min or go to (hospital). 5. Apply sterile bandage or dressing. 6. Apply ice pack to area over dressing to aid clotting and decrease pain. 7. Call parent/guardian to come if bleeding continues more than 20 min. or need for sutures. 8. Call parent even if bleeding stops within 20 min. or if no need for sutures to inform of injury. 9. Call 911 if bleeding continues or is severe or if parent cannot be reached. If student receives an injury or a fall affecting 1. Call parent immediately. the head, throat, neck, abdomen, back, or groin 2. Call doctor or hospital/care center if the parent cannot be reached. area 3. Call 911 if parent cannot be reached and there has been an injury to the head, throat, neck, abdomen, back, or groin area within last week and student complains of pain, swelling, or tightness. 4. Have student rest and keep student calm. 5. Call 911 if signs of irritability, confusion, drowsiness, trouble breathing, sweating, cold, clammy skin, stiff neck, or seizure activity. 6. Apply ice to affected area. Signs and symptoms of internal bleeding 1. Bruising/discoloration/swelling/pain of injured area. 2. Blood in urine (urine may be pink, red, or cola colored). Note: A slow bleed after trauma may delay 3. Vomit or respiratory secretions with red or brown material. symptoms for days. 4. Severe headache, irritability, confusion, drowsiness. 5. Trouble swallowing or breathing. 6. Blurred or double vision, vision changes, unequal pupils. 7. Blood in stools (tarry or bloody). 8. Inability to raise the leg on the injured side. Parent/Guardian to Complete Type of Hemophilia:______ Mild  Moderate  Severe  Replacement Factor required. Additional comments/instructions:______

Signature: ______Date: ______