To be completed by healthcare provider
School Nurse: Parent/Guardian’s Signature: policies Education of Board their with compliance in liability any from personnel and school the release and devices delivery/monitoring and medication prescribed with school the providing for responsibility full assume I provider. health our care contact pe school for permission give I of is capable and instructed been has Student DOSAGE Asthma: ____ HISTORY: Name: Student’s
ALLERGY TO: TO: ALLERGY School: _
agitation Confusion, happen, to about is bad something Feeling OTHER: com or severe (if diarrhea or Vomiting GUT: redness widespread body, over hives Many SKIN: dizzy pulse, weak faint, blue, Pale, HEART: S MOUTH: breathing/swallowing trouble hoarse, Tight, THROAT: cough repetitive wheeze, breath, of Short LUNG: SYMPTOMS: SEVERE Provider’s Signature: _ Pr 3. 2. 1.
SKIN: itch Amild hives, few NOSE: runnyItchy, nose, sneezing ONLY SYMPTOMS MILD ______If symptoms do not improve Asthma Rescue Inhaler Inhaler Rescue Asthma Antihistamine GUT: Mild nausea/discomfort ovider (print) _
a. Emergency contacts: Name/Relationship Parent: ______epinephrine, oxygen, or other medications may be needed. If epinephrine given, c b. ______Teacher: ______
: Colorado
Epinephrine ______1) ______1) ______2)______NO NO
YES Date: Date: ______
______
with other symptoms other with (h welling of the tongue and/or lips and/or tongue the of welling
: igher igher (brand and dose and (brand ______Allergy : inject intramuscularly inject using risk severe for reaction) – rsonnel to share this information, follow this plan, administer medication and care for my child and, if necessary, necessary, if and, child my for care and medication administer plan, this follow information, this share to rsonnel ______Date: ______Date: ______
Any of the following: the Anyof (brand and dose) and (brand
DO DO ____ and al :
l 911.l NOT HESITATE TO ADMINISTER EMERGENCY MEDICATIONS EMERGENCY ADMINISTER TO HESITATE NOT minutes or more
______Grade: ______D.O.B. ______
◊ STEP 2: EMERGENCY CALLS ◊ CALLS EMERGENCY 2: ◊ STEP State that an anaphylactic an that State
STEP 1: TREATMENT
refer to their asthma care plan care asthma their to refer
carrying and
, or symptoms return, 2
auto injector auto Emergency Care b
ined ined
Phone Number:
- self Phone Number(s)
____ (check one): administering
reaction has beentreated andadditional ______
nd 3. orders) Do not use other medicine in place of of place in medicine other use not Do orders) for below (see prescribed. if medicine, other Give 2. 1. 2. 2. 1. epinphrine
dose of epinephrine
Plan If If Stay with child and child with Stay
GIVE progress symptoms and follow directions in above box in above directions and follow
• • • and child with Stay • • 911 Call INJECT EPINEPHRINE IMMEDIATELY EPINEPHRINE INJECT • • ______mild more or two
_
______
______
Phone Number: ______
student put breathing, difficulty or vomiting If . down lying them keep student; Monitor below instructed as available if epi of dose second give worsen or improve don't symptoms If Cal Tell EMS when epinephrine was given was epinephrine when EMS Tell epinephrine with ambulance for Ask Give antihistamine (if prescribed) (if antihistamine Give nurse school and parent Alert own medication. medication. own and Medication Orders Medication and
0.3 mg
. l parent/guardian and school nurse school and l parent/guardian US
2) _ . . ______E
on side
EPINEPHRINE
______
should _ _
symptoms present or or present symptoms
0.15 mg
______be be
Yes EPINEPHRINE given Place child’s Place photo here photo
if No
available
_
Student Name: ______DOB: ______
Staff trained and delegated to administer emergency medications in this plan:
1.______Room ______
2.______Room ______
3.______Room ______
Self-carry contract on file: Yes No
Expiration date of epinephrine auto injector: ______
Keep the child lying on their back. If the child vomits or has trouble breathing, place child on his/her side.
If this conditions warrents meal accomodations from food service, please complete the form for dietary disabilitiy if required by district policy.
Additional information:______Adopted from the Allergy and Anaphylaxis Emergency Plan provided by the American Academy of Pediatrics, 2017
January 2018