Severe Allergic Reaction Care Plan Template (2015)
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1
2Date Received __________
MUKWONAGO AREA SCHOOL DISTRICT—HEALTH SERVICES
CLEAR FORM
Date Revised ___________
DISTRICT NURSE PHONE: 262-363-6292 X27515 FAX: 262-363-6320
Select Year
SEVERE ALLERGIC REACTION CARE PLAN for
Student Name:
Severe ALLERGY to:
Please list the specific symptoms the student has
Does student have Asthma?
experienced in the past:
No
Yes (See Asthma Care Plan)
Other allergies / health problems:
Date of Birth:
School:
Grade:
Routine medications (at home and school)
Select One
Select One
Transportation:
Bus # __________
Car
Walk
Date of last reaction:
Location where EpiPen/Auvi-Q(s) / Rescue medication(s) is/are stored:
Preferred Hospital:
Health Office
Backpack
On Person
Locker # __________
Other _____________
Extremely reactive to the following: __________________________________________________________________
THEREFORE:
If checked, give epinephrine immediately for ANY symptoms if the allergen was likely eaten.
If checked, give epinephrine immediately if the allergen was definitely eaten, even if no symptoms are noted.
If you suspect a mild allergic reaction:
MILD SYMPTOMS after suspected or known ingestion:
1
. GIVE ANTIHISTAMINE
MOUTH:
Itchy mouth
2. Stay with student; alert health assistant,
SKIN:
A few hives around mouth / face, mild itch
parent, and district nurse.
STOMACH:
Mild nausea / discomfort
3. If symptoms progress ( see below)
If you suspect a severe allergic reaction:
Any SEVERE SYMPTOMS after suspected or known ingestion:
1. INJECT EPINEPHRINE IMMEDIATELY
MOUTH:
Itching, tingling, or swelling of the lips, tongue, or mouth
2. Call 911 – Inform EpiPen/Auvi-Q is being
SKIN:
Hives, itchy rash, and/or swelling about the face or extremities
administered and time given.
THROAT:
Sense of tightness in the throat, hoarseness, and
3. Stay with student; alert health assistant,
hacking cough
parent, and district nurse.
STOMACH:
Nausea, stomachache/abdominal cramps, vomiting,
4. Monitor for further allergic reaction
and/or diarrhea
5. Give additional medications: *
LUNG:
Shortness of breath, repetitive coughing, and/or wheezing
- Antihistamine—as ordered below
HEART:
“thready” pulse, “passing out,” fainting, blueness, pale
- Inhaler (bronchodilator) if asthma
GENERAL:
Panic, sudden fatigue, chills, fear of impending doom
*Antihistamines & inhalers/bronchodilators are not to
OTHER:
Some students may experience symptoms other than
be depended upon to treat a severe reaction
those listed above
(anaphylaxis). USE EPINEPHRINE
MEDICATION ORDERS - FOR EPINEPHRINE and ANTIHISTAMINE
Possible side Effects:
EpiPen Jr. / Auvi-Q (0.15mg)
EpiPen / Auvi-Q (0.3mg)
Repeat dose of EpiPen / Auvi-Q
Yes
No
If YES, when
Antihistamine—Medication Name:
Dose by mouth; _______ Teaspoons
______ Tablets ______Melt Away
Frequency:
Strength __________ cc/mg
Side Effects:
It is medically necessary for this student to carry an EpiPen / Auvi-Q during school hours.
Yes
No
Student may self-administer EpiPen / Auvi-Q
Yes
No
Student has demonstrated use to Health Care Provider
Yes
No
Additional Instructions:
Health Care Provider Signature :
Date:
Phone Number:
Fax Number:
EVEN IF PARENT/GUARDIAN CANNOT BE REACHED, DO NOT HESITATE TO MEDICATE OR CALL 911
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Revised 05/26/2015 by LAH
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