PLACE A PICTURE OF YOUR CHILD HERE.
SEVERE OR SERIOUS ALLERGY
Student’s name__________________________________________
D.O.B. __________________ Grade_________________________
Allergies are currently being treated by: Dr.____________________________________________________
Phone: ________________________________________________
Is your child asthmatic Yes__________ No____________________
I give my permission for the use of my child’s photograph for this purpose and to share medical information with appropriate school related personnel yes______ no______
Check any life-threatening allergy your child has:
Insect stings (list type)
Food (list type)
Animals (list type)
Other (list)
Check the signs that are usually present during an allergy attack:
Difficulty breathing, repetitive coughing, wheezing
Itchy rash, hives
Difficulty swallowing, sense of itching tightness or in throat, hoarseness
Nausea, vomiting, diarrhea, abdominal cramps
Loss of consciousness
Flush/ unusually pale skin
Swelling: How much?
Where?
Other
Action for minor reaction:
If the only symptom (s) are: ______________________________________________________________________________
Give__________________________________________________________________________
(medication/dose/route)
If condition does not improve within 10 minutes, continue with action for a major reaction.
Action for major reaction:
If ingestion is suspected and/or symptoms are ________________________________________
Give_______________________________________________________________immediately!
(medication/dose route)
*CALL 911 IMMEDIATELY*
SEVERE OR SERIOUS ALLERGY
Emergency Numbers
1. Mother (h)_________________________(w)__________________________________
2. Father (h)_________________________(w)___________________________________
3. Doctor _________________________________at_______________________________
4. Other emergency contact___________________________________________________
Relationship______________________________#______________________________
5. Other emergency contact___________________________________________________
Relationship________________________________#____________________________
Has emergency medical treatment been needed in the last year for allergies?
Yes
No
I give permission for the school nurse or his/her delegated personnel to administer the above medications at school or on school related events. Yes___________ No_____________
This student has permission to self-administer the above medications at school or on school related events, if the school nurse deems it is appropriate. Yes________ No_____________
STUDENTS ARE EXPECTED TO CARRY THEIR OWN EPI-PEN AT ALL TIMES.
Parent’s Signature___________________________________________date________________
Doctor’s Signature__________________________________________date________________
SEVERE OR SERIOUS ALLERGY
Emergency care in school:
Stay with student, call or have someone call for nurse immediately.
Ask student if he/she uses an Epi-pen and if he/she has one with them.
Send another person to get the Epi-pen if available.
If nurse not present or available, call for someone trained in Epi-pen administration.
Never send a student to the nurse alone if symptoms above are present.
Trained staff members
1. _________________________________________room________________________
2. _________________________________________room_________________________
3. _________________________________________room_________________________
Epi-Pen and Epi-Pen jr. Directions
1. Pull off grey cap
2. Place black tip on upper outer thigh (always apply to thigh)
3. Using a quick motion, press hard into thigh until auto-injector mechanism functions. Hold in place and count to 10. The Epi-pen unit should then be removed and discarded. Massage the injection site for 10 seconds
For RN use only
Reviewed on
Nursing diagnosis
Plan
( ) stable history
No ongoing nursing management at school indicated
( ) potential for anaphylaxis
Standard procedure for severe allergic reaction
( ) other
Individualized health care plan
( ) high risk for ineffective breathing pattern
( ) delegated or
( ) assigned caregiver
RN signature
(Severe allergy cont., school use only, revised 5/03)
|