Colorado Allergy And Anaphylaxis Emergency Care Plan And Medication Orders Sheet
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2Colorado Allergy and Anaphylaxis Emergency Care Plan and Medication Orders
Student’s Name: _____________________________________D.O.B. __________ Grade: ____________
School: ____________________________________________ Teacher: ___________________________
Place child’s
ALLERGY TO:
____________
photo here
HISTORY:
_______________________________________________________________________
______________________________________________________________________________________
Asthma:
YES (higher risk for severe reaction)
NO
◊ STEP 1: TREATMENT
Give epinephrine immediately if the allergen was
1. INJECT EPINEPHRINE IMMEDIATELY
definitely ingested, even if no symptoms
2. Call 911 and activate school emergency
response team
SEVERE SYMPTOMS: Any of the following:
3. Call parent/guardian and school nurse
LUNG:
Short of breath, wheeze, repetitive cough
4. Monitor student; keep them lying down
HEART:
Pale, blue, faint, weak pulse, dizzy,
5. Administer Inhaler (quick relief) if ordered
THROAT: Tight, hoarse, trouble breathing/swallowing
nd
6. Be prepared to administer 2
dose of
MOUTH: Significant swelling of the tongue and/or lips
epinephrine if needed
SKIN:
Many hives over body, widespread redness
*Antihistamine & quick relief inhalers are not to
GUT:
Repetitive vomiting, severe diarrhea
be depended upon to treat a severe food
OTHER:
Feeling something bad is about to happen,
related reaction .
USE EPINEPHRINE
confusion
1. Alert parent/guardian and school nurse
MILD SYMPTOMS ONLY:
2. Antihistamines may be given if ordered by
NOSE:
Itchy, runny nose, sneezing
a healthcare provider,
SKIN:
A few hives, mild itch
3. Continue to observe student
GUT:
Mild nausea/discomfort
4. If symptoms progress USE EPINEPHRINE
5. Follow directions in above box
DOSAGE:
0.3 mg
0.15 mg
Epinephrine
inject intramuscularly using auto injector (check one):
:
nd
If symptoms do not improve in_______minutes, or if symptoms return, 2
dose of epinephrine should be
given, if available.
Antihistamine: (brand and dose)_______________________________________________________________
Asthma Rescue Inhaler: (brand and dose)________________________________________________________
Student has been instructed and is capable of carrying and self-administering own medication.
Yes
No
Provider (print) __________________________________________________Phone Number: ______________
Provider’s Signature: _____________________________________________ Date: _______________________
If this condition warrants meal accommodations from food service, please complete the medical statement for dietary disability
◊ STEP 2: EMERGENCY CALLS ◊
1. If epinephrine given, call 911. State that an allergic reaction has been treated and additional
epinephrine, oxygen, or other medications may be needed.
2. Parent: ________________________________ Phone Number: ____________________________
3. Emergency contacts: Name/Relationship
Phone Number(s)
a. _______________________________________1) _______________ 2) ________________
b. _______________________________________ 1) ______________ 2) ________________
EVEN IF PARENT/GUARDIAN CANNOT BE REACHED; DO NOT HESITATE TO ADMINISTER EMERGENCY MEDICATIONS
I give permission for school personnel to share this information, follow this plan, administer medication and care for my child and, if necessary,
contact our health care provider. I assume full responsibility for providing the school with prescribed medication and delivery/monitoring devices.
I approve this Severe Allergy Care Plan for my child.
Parent/Guardian’s Signature: ______________________________________________
Date: _______________________
School Nurse: ___________________________________________________________
Date: ________________________
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