I Approve of This Plan As Written

EMERGENCY PLAN 2008-09

STUDENT Student One / SCHOOL XX Elementary
RESTRICTIONS Avoid activities that present a risk of falling. No rock wall climbing. Elevated play structure activities with railings are OK. / Choose oneCLASSROOMTEAM teacher
CONDITION Seizure disorder - Has absence and myoclonic seizures. Absence seizure – appears to stare into space for a few seconds, but does not typically fall. There may be slight rhythmic movements of the eyelids, hands, head, or other body part. Recovery is immediate after the seizure, with no lingering confusion.
Myoclonic seizure – rapid, brief contractions of bodily muscles, which usually occur at the same time on both sides of the body. Occasionally, they involve one arm or a foot. In the past, Student One's myoclonic seizures have involved both arms.
Student One has not had a tonic clonic (generalized) seizure to date. / GRADE Choose onePre-KK123456789101112______
ACTION PLAN FOR EMERGENCY
1.  Call health office by phone (XXXX) stating Student One's name, problem and location. Contact school nurse via walkie-talkie, if outside of the building.
2.  Prevent or minimize injury during absence or myoclonic seizure:
a. note time of onset and end of seizure.
b. do not put anything in Student One's mouth.
c. observe Student One's behavior/movements/color; and share with nurse.
d. remove objects in the immediate area.
e. do not restrain, but protect from injuring himself.
f. observe for breathing difficulty, repositioning Student One if needed so that his airway is
unobstructed.
g. offer reassurance.
h. if vomiting occurs, try to turn head to one side to facilitate drainage of
oral secretions.
3.  Ask someone to document observations on seizure observation log or complete seizure observation log after your assistance is no longer needed.
4.  Nurse will bring oxygen and assess Student One’s status.
5. If absence or myoclonic seizure lasts less than three minutes:
a. nurse will move Student One to health office when feasible; reassess and monitor status.
b.  nurse will notify parent and doctor.
6.  If absence or myoclonic seizure lasts more than three minutes, or a tonic clonic seizure lasts more than five minutes:
a.  nurse will direct someone to call EMS (9-9-1-1), main office and parent
b.  nurse will monitor status until EMS arrives.
EMERGENCY CONTACTS / PHYSICIAN INFORMATION
1.  Name XXXXXXXX
Relation mother
Phone h. 203-XXXXX c. 203-XXX-XXXX / 1.  Name Dr. XXXXX
Specialty pediatrician
Phone XXXXX
2.  Name XXXXXXX
Relation father
Phone w. 212-XXX-XXXX c. 917-XXX-XXXX / 2.  Name Dr. XXXXX
Specialty pediatric neurology
Phone XXXXXXX
3.  Name XXXXXX
Relation grandmother
Phone c. 203-XXX-XXXX / 3.  Name
Specialty
Phone

Period of plan from: X/XX/XX to X/XX/XX Projected date for review: X/XX

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Parent Student (if applicable) School Nurse

School Health Services: Rev: 9/05 PUBLIC SCHOOLS Side 1 of 2