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:__________
Name:________________________________________________________ Room:__________
Name:________________________________________________________ Room:__________
Name:________________________________________________________ Room:__________
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.