Seizure Health Plan And Emergency Action Plan Page 2
ADVERTISEMENT
1
2Page 2 - Seizure Health Management Plan
SEIZURE INFORMATION:
Seizure Type
Length
Frequency
Date Last Seizure
Describe signs/symptoms usually seen
How old was child when seizures started? _____________________________________________________________________
What has triggered a seizure in the past (fever, noise, lights)? _____________________________________________________
How does your child act before a seizure? ____________________________________________________________________
How does your child act after a seizure? ______________________________________________________________________
Does child have a Vagal Nerve Stimulator (VNS)? Yes
No (circle one)
If “Yes”, please contact the health room for additional VNS form
9-1-1 SEIZURE EMERGENCY PROTOCOL:
It lasts longer than 5 minutes or student has 3 seizures within 1 hour
Student has repeated seizures without regaining consciousness
Student is injured during a seizure or experiences a seizure while in water
Action Steps:
1.
Seizure First Aid
2.
Call 9-1-1 for assistance and transport
3.
Administer Emergency medication
4.
Notify parent(s) and District Nurse(s)
5.
Complete Seizure Record Log
Health Care Provider Name (print):_________________________________ Phone:_______________
Health Care Provider Signature: ____________________________________ Date:_______________
---------------------------------------------------------------------------------------------------------------------------------
BELOW SECTION - FOR SCHOOL USE ONLY
• Date received: ___________________________
• Name of person(s) who will administer the Medication:
_____________________________ ___________________________ _______________________
• Approved by: ____________________________________________ _______________________
(Principal’s Signature)
(Date)
• ________ Referred for administrative review. Send to District Nurse with
concerns about authorization.
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business