Board Policy JHCD-R3:
Pulaski County Schools
Student Seizure Disorder Health Care Plan
Student name: _________________________________________________DOB: __________________________
The following is to be completed by physician:
______This student has been diagnosed with a Seizure disorder.
Comments/Special instructions specific to this student: _________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
**Any medication needed by student at school will require that a Medication Authorization form be
completed and signed by a physician and parent/guardian.
Signs of Seizure activity include: staring/visual disturbance jerks, unusual smell/tastes, involuntary
rigidity/jerking/shaking, becomes unresponsive, behavior changes, shallow breathing, and bluish skin,
possible loss of bowel/bladder control.
These signs indicate the need for the following care:
•
Protect head from injury
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Turn student on his/her side to keep airway clear
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Clear area and provide privacy
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Loosen collar if needed
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Do not restrain student
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Do not move student if injury has occurred
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Remain with the student
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Document seizure activity, include date, time, duration, objective facts about seizure behavior.
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Monitor breathing and, if necessary, begin rescue breathing after muscle jerks subside.
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Call 911-if seizure last more than five minutes, if multiple seizures occur; student is pregnant,
injured, or diabetic.
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Notify principal and call parents/guardian
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Record and send with person transporting documentation of seizure activity and other significant data,
along with a copy of this plan.
Please list any special considerations/activity restrictions/treatments related to student’s seizure disorder:
Please list any special precautions for field trips/transportation to and from school: ___________________________
_____________________________________________________________________________________________
This plan is in accordance with the student’s medical management and is to be followed at school.
Physician signature: ____________________________________________________Date: ____________________