Seizure Care Plan Form (2015)
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2MUKWONAGO AREA SCHOOL DISTRICT—HEALTH SERVICES
Date Received ___________
CLEAR FORM
DISTRICT NURSE PHONE: 262-363-6292 X27515 FAX: 262-363-6320
Date Revised ____________
SEIZURE CARE PLAN for
Select Year
Student Name:
When diagnosed with seizures/epilepsy:
Routine medications (at home and school)
Date of Birth:
School:
Grade:
Select Grade
Select School
Other health problems:
Transportation:
Bus # ___________
Car
Walk
Location(s) where Seizure medication is/are stored:
Preferred Hospital:
Health Office
Backpack
On Person
Other __________
Signs of seizure activity may include:
Staring / Rapid eye blinking
Jerking movements of the arms and legs
Stiffening of the body
Loss of consciousness
Breathing problems or breathing stops
Loss of bowel or bladder control
Nodding the head
Not responding to noise / touch for brief periods
Lip smacking / sucking / drooling
Flushed or Pale skin tone
Falling suddenly for no apparent reason
Appearing confused or in a haze
Lips become blue
Sweating
Other: ______________________
If seizure activity occurs, provide the following measures:
Remain calm! No one can stop a seizure once it starts.
Note what time seizure activity started, part of body involved, type of movement, any injury, any breathing problems, and student color.
Remain with student and send another student or staff member for help.
Clear room of other students and provide as much privacy as possible.
Protect student’s head from injury by placing folded blanket, towel or jacket under head.
If possible assist student to lie down on his/her side to keep airway clear from saliva and vomit.
Do not attempt to hold down or restrain student's movements. (This may cause fractures or bruising)
Do not place objects, food, drink or medication in mouth. (This may cause aspiration, vomiting, broken teeth, bitten tongue)
Do not move student if injury has occurred.
Administer medication as prescribed. (See Health Care Providers Orders below)
Notify parent/guardian and district nurse. (Refer to page 2 of seizure care plan for emergency contact phone numbers)
Special Instructions: ______________________________________________________________________________________________
CALL 911 for ANY of the following:
Seizure lasts more than _______ minutes.
Diastat is administered.
Student stops breathing or does not have a pulse. (Perform CPR if required)
There is evidence of injury or seizure occurs in water.
Student cannot be awakened, pupils are not equal in size and/or vomits continuously after seizure has ended.
Other: ______________________________________________________________________________________________________
After a seizure is over:
Monitor student’s breathing and allow to rest for at least 30 minutes. Orient student to surroundings and call parent if not already called. Make sure
documentation of seizure is completed and district nurse is notified.
EVEN IF PARENT/GUARDIAN CANNOT BE REACHED, DO NOT HESITATE TO MEDICATE OR CALL 911
For anyone with an unknown seizure disorder—Follow the above safety steps, Call 911 and send for AED
HEALTH CARE PROVIDERS ORDERS —FOR DIASTAT, CLONAZEPAM, & VAGAL NERVE STIMULATOR
As needed for Seizure activity:
Diastat Strength: _________ mg
Diastat Dose: _________ mg
Lasting beyond ________ minutes
No Diastat is needed at this time
3 or more seizures in an hour
Possible Side Effects:
Additional Instructions:
Vagal Nerve Stimulator (VNS) magnet
Clonazepam Strength: ___________________ Dose: ____________mg
Hold magnet over implant
As needed for Seizure activity:
Count 1—one thousand, 2—one thousand, 3—Remove
Before Diastat
Repeat every _________ seconds
At onset of Seizure
Discontinue use of magnet if seizure activity stops
Seizure lasting longer than _______minutes
Other: _________________________________________
Side effects: ________________________________________
Health Care Provider Signature :
Date:
Phone Number:
Fax Number:
Page 1 of 2
Revised 05/14/2015 by LAH
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