Policy 3515F - Emergency Care Plan

RISE CHARTER SCHOOL

DISTRICT #562

STUDENTS 3515F

Emergency Care Plan

Name: __________________________________________

Date of Birth: __________________________________________

School: __________________________________________

Grade: __________________________________________

Known Allergies and or Food Allergies: _______________________________________

________________________________________________________________________________

Asthmatic? Yes:*_____ No: _____

*Higher risk for severe reaction

STEP 1: TREATMENT

NOTE: Different symptoms may occur with any reaction and the severity of symptoms can change rapidly. Delay in treatment can be fatal. A high level of vigilance must be maintained for any symptoms exhibited by a student with food allergies. Act quickly!

Symptoms

Select the medication to be given in each circumstance (To be determined by physician authorizing treatment).
Food allergen has been ingested, but no symptoms:	Epinephrine:	Antihistamine:
MOUTH: Itchy, tingling, or swelling of lips, tongue, mouth	Epinephrine:	Antihistamine:
SKIN: Hives, itchy rash, swelling of the face or extremities	Epinephrine:	Antihistamine:
GUT: Nausea, abdominal cramps, vomiting, diarrhea	Epinephrine:	Antihistamine:
THROAT: Tightening of throat, hoarseness, hacking cough	Epinephrine:	Antihistamine:
LUNG: Shortness of breath, repetitive coughing, wheezing	Epinephrine:	Antihistamine:
HEART: Thready pulse, low blood pressure, fainting, pale, blue	Epinephrine:	Antihistamine:
OTHER:	Epinephrine:	Antihistamine:
If more than one of the above areas is affected	Epinephrine:	Antihistamine:

Dosage (to be determined by physician authorizing treatment)

Epinephrine: (circle one) EpiPen EpiPen Jr. Twinject 0.3 mg Twinject .15mg

Inject intramuscularly (see following page for instructions)

Antihistamine: ________________________________________________________________

(medication/dose/route)

Other: _______________________________________________________________________

(medication/dose/route)

Important: Asthma inhalers and antihistamines cannot be depended on to replace epinephrine in anaphylaxis.

STEP 2: EMERGENCY CALLS

Important: Even if a parent or guardian cannot be reached, do not hesitate to medicate or take the child to a medical facility.

Call 911. State that an allergic reaction has been treated and additional epinephrine may be needed. Send someone to meet the emergency services personnel at the School entrance and direct them to the site of the incident. The student will need to be transported to the hospital for further observation.

Notify the School nurse and School principal. Normally the administrator or their designee will make the rest of the emergency calls.

Dr.____________________________________ Phone Number:___________________

Parent:_________________________________ Phone Number:___________________

Parent:_________________________________ Phone Number:___________________

Emergency Contacts:

Name/Relationship:________________________________________________________

Phone Number(s):_________________________________________________________

Name/Relationship:________________________________________________________

Phone Number(s):_________________________________________________________

Parent/Guardian Signature:____________________________________ Date:______________

Doctor’s Signature: __________________________________________ Date:______________

Epinephrine Directions

The following staff members have been trained to use the epinephrine auto-injectors:

Name:________________________________________________________ Room:__________

Once the EpiPen or Twinject is used, call 911. Take the used unit with you to the emergency room. Plan to stay for observation at the emergency room for at least 4 hours.