Emergency Health Care Plan Form
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1
2Emergency Health Care Plan
SEVERE ALLERGY TO: ___________________________________________
Child’s Name ____________________________________ DOB ______________Current Weight ___________
Child Care Program _______________________________ Child Care Provider__________________________
EMERGENCY TREATMENT
For Mild Symptoms
o Several Hives
o Itchy skin
OR If an ingestion (or sting) is suspected
o Swelling at site of an insect sting
Treatment
1. Stay with the Child
2. Give _________________ of _________________ by mouth.
Dose (amount)
medication
3. Contact the parent or emergency contact person.
4. Stay with the child; keep child quiet, monitor symptoms until parent arrives.
Watch child for more serious symptoms listed below.
Life Threatening Reaction
Severe Symptoms can cause a
Hives spreading over the body
Wheezing, difficulty swallowing or breathing
Swelling of face/neck, tingling or swelling of tongue
Vomiting
Signs of shock (extreme paleness/grey color, clammy skin)
Loss of consciousness
Treatment
1. Give EpiPen® or EpiPen Jr.® immediately, place against upper outer thigh,
through clothing if necessary.
2. CALL 911 (or local emergency response team) immediately.
EpiPen® only lasts for 20 – 30 minutes
911 (emergency response team) should always be called if EpiPen® is given
3. Contact parents or emergency contact person. If parents unavailable, child care staff
member should accompany the child to the hospital.
Directions for use of EpiPen®:
1. Pull off grey cap.
2. Place black tip against upper outer thigh.
3. Press hard into outer thigh, until it clicks.
4. Hold in place 10 seconds, and then remove.
5.
Discard EpiPen® in impermeable can. Dispose per policy,
.
or give to emergency care responder. Do not return to holder
Special Instructions
(for health care provider to complete):
___________________________________________________________________________________________
___________________________________________________________________________________________
It is understood by the parent(s) and health care provider that this plan will be carried out by child care personnel per the directions given above.
Prescribing Practitioner Signature _______________________________________
Date _______________
Parent/Guardian Signature _____________________________________________
Date _______________
-
10/06
EMERGENCY HEALTH CARE PLAN
SEVERE ALLERGY
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