Severe Allergy/anaphylaxis Action Plan And Treatment Authorization Form printable pdf download

VA Planning District 16 School Health T.E.A.M

Severe Allergy/Anaphylaxis Action Plan and Treatment Authorization

Child’s

Photograph

Name:______________________________________

DOB_____________________

Teacher:____________________________________

Grade:___________________

Allergy to:________________________________________________________________

Weight:_______lbs __________kg

Asthma: Yes:______ No:_______ (higher risk for a severe reaction)

RECOGNIZE SEVERE ANAPHYLAXIS SYMPTOMS:

INJECT EPINEPHRINE IMMEDIATELY!!

LUNG: shortness of breath, wheezing, repetitive cough

1. 1. Call 911

Heart: Pale, blue, faint, weak pulse, dizzy, confused

2. 2. Begin Monitoring

THROAT: tight, hoarse, trouble breathing/swallowing,

3. 3. Administer Rescue Inhaler if

MOUTH: Swelling of the throat, lips, tongue, metallic

asthmatic

taste

4. 4. Give additional medications

SKIN: generalized flushing or itching, hives (rash), swelling

**Inhalers/Bronchodilators and

GUT: Vomiting, cramps, diarrhea, nausea

antihistamines are NOT to be

Any ONEor COMBINATION of the above symptoms from

depended on to treat a severe

different body areas can progress rapidly to a life

reaction (anaphylaxis).

threatening situation!!

USE EPINEPHRINE!

1. 1. Give Antihistamine

MILD SYMPTOMS ONLY:

2. 2. Stay with student, call parents

MOUTH: Itching without swelling, especially seen with

3. 3. If symptoms progress, USE

ingestion of fresh fruits

EPINEPHRINE

SKIN: Limited redness of skin/few small hives

4. 4. Begin Monitoring

______ If checked, administer epinephrine for ANY symptoms if there was possible exposure

______ If checked, administer epinephrine BEFORE symptoms occur, if there was known exposure

MEDICATIONS/DOSES:

EPINEPHRINE AUTO-INJECTOR: (BRAND AND DOSE): EpiPen_______ EpiPen JR______ Auvi-Q______ Auvi-Q JR______

BRONCHODILATOR: (BRAND AND DOSE):

_____________________________________________

ANTIHISTAMINE: (BRAND AND DOSE):

_____________________________________________

(*** Antihistamines should NOT be used as a first line of treatment during an anaphylaxis episode. It will treat itching ONLY – it will

not halt vascular collapse or swelling!!)

MONITORING: Stay with student. Alert Health Care professionals and parent. Tell rescue squad epinephrine was given and

request an ambulance with epinephrine. Note time when epinephrine was administered. A second dose of epinephrine can

be administered within 5 minutes if symptoms persist or recur. For a severe reaction consider keeping student lying on back

with legs raised. Treat student even if parents cannot be reached.

___ Student may carry epinephrine

___ Student may self-administer epinephrine

___ *Classroom accommodations needed

EMERGENCY CONTACTS: 911

Rescue Squad:__________________________

Parent/Guardian:________________________

Phone:_____________________________

Name/Relationship:______________________

Phone:_____________________________

LICENSED HEALTH CARE PROVIDER (signature):_____________________________________

Date:_____________

Printed name of Health Care Provider: ______________________________________

Phone:________________

I hereby authorize the school district staff members to take whatever action in their judgment may be necessary in providing emergency medical treatment

consistent with this plan, including the administration of medication to my child. I understand the Virginia School Health Guidelines , Code of Virginia, 8.01-225

Protects school staff members from liability arising from actions consistent with this plan. I also hereby authorize the school district staff to disclose my child’s

protected health information to chaperones, and other non-employee volunteers at the school or school events and field trips to the extent necessary for the

protection, prevention of an allergic reaction, or emergency treatment of my child and for the implementation of this plan.

Parent/Guardian Signature: __________________________________________________ Date:_________________

Revised 4/14 PD16 TEAM