Care Plan/ Emergency Action Plan-Seizures Form
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1
2WASHINGTON YOUTH ACADEMY
CARE PLAN/ EMERGENCY ACTION PLAN-SEIZURES
Cadett’s Name: __________________________________________ Date of Birth: _________ Age when diagnosed____________
Parent/Guardian’s Name: ____________________________________________________
Phone #: ______________________
____________________________________________________
Phone #: ______________________
Doctor’s Name: ____________________________________________________________
Phone #: _______________________
What type of seizure does child have? _________________________ How often do the seizures occur? _________________________
How long has it been since his/her last seizure? ________________________________________________________________________
Does he/she experience an aura before having a seizure? _______ If yes, describe: ____________________________________________
MEDICATION NAME
DOSE/ AMOUNT TAKEN
HOW OFTEN?
WILL MEDICATION BE NEEDED
AND TAKEN AT SCHOOL?
Dose student have a Vagus Nerve Stimulator (VNS)? _________ Where is the magnet worn? _____________________________
Describe use of the magnet: _______________________________________________________________________________
SIGNS OF SEIZURES: PLEASE CHECK BEHAVIORS THAT APPLY TO YOUR CHILD.
SIMPLE
GENERALIZED
DANGER SIGNS-
BEHAVIORS EXPECTED
SEIZURES
SEIZURES
AFTER SEIZURE
CALL 911
□
□
Seizure lasts more than 5 minutes
Tiredness
Lip smacking
Sudden cry or squeal
□
□
Another seizure starts right after
Weakness
Behavioral outbursts
Falling down
st
the 1
seizure
Sleeping, difficult to arouse
□
□
Staring
Rigidity/Stiffness
Loss of consciousness
Somewhat confused
□
□
Twitching
Thrashing/Jerking
Stops breathing
Regular breathing
□
□
Other: ______________
Loss of bowel/bladder control
If student has diabetes
Other: _____________________
□
Shallow breathing
If seizure is the result of an
□
injury or child is injured during
ALL OF ABOVE CAN LAST A FEW
Stops breathing
□
seizure
MINUTES TO A FEW HOURS.
Blue color to lips
If student is pregnant
□
Froth from mouth
If student has never had a seizure
□
Gurgling or grunting noises
before
□
Loss of consciousness
□
Other: __________________
IF YOU SEE THIS
DO THIS
SEIZURE ACTIVITY
Stay calm. Move surrounding objects to avoid injury. Do not hold the student down or put anything
in the mouth. Loosen clothing as able. After seizure stops, roll student on his/her side. Document
seizure activity on back of this form. If applicable, administer medications as ordered. Notify their
parent/guardian and school RN.
STOPS BREATHING
Begin CPR/Rescue breathing. Call 911
LOSS OF BOWEL OR BLADDER
Cover with blanket or jacket. If necessary: discreetly assist with changing of clothes after seizure.
CONTROL
DANGER SIGNS-SEE ABOVE
Call 911. Then call parent/guardian.
FALLS DOWN,
Help student to the floor for observation and safety
LOSS OF CONSCIOUSNESS
VOMITING
Turn on side
DATE
PARENT SIGNATURE
NURSE SIGNATURE
SIGNATURES
PLAN INITIATED
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