Seizure Action Plan

SEIZURE ACTION PLAN

School Year ________

Palo Alto Unified School District

School ____________________________________

25 Churchill Avenue Palo Alto, CA 94306

Health Services Linda Lenoir RN, MSN 650-329-3766 Fax 650-833-4226

School Fax _______________________________

 

 

                                       

This student is being treated for a seizure disorder. The information below may assist if a seizure occurs during school hours or at school activities

 

Student Name:__________________________________ ______________________________________ DOB: __________________________

Parent/Guardian:________________________________ Phone: _______________________________ CELL:__________________________

Primary Physician:_______________________________ Phone:_________________________________ FAX:___________________________

Neurologist:____________________________________ Phone:_________________________________ FAX:___________________________

PHYSICIAN COMPLETES FORM FROM THIS POINT FORWARD

S

ignificant Medical History: ______________________________________________________________________________________________

Seizure Type

Length

Frequency

Description

Date of Last Seizure

_______________

Seizure triggers or warning signs: __

________________________________________________________________________

SEIZURE BASIC

SEIZURE RESPONSE – BASIC

è

è

è

• Stay calm and record time of seizure

Student Response after a Seizure:

• Keep student safe but DO NOT restrain

__________________________________________________________________________

_

_

• Do not put anything in mouth

__________________________________________________________________________

• Stay with student until fully conscious

__________________________________________________________________________

• Document ending time and description of seizure

Does student need to leave classroom after a seizure?

Yes

No

Tonic-Clonic Seizure additional response:

• Protect Head

If YES, describe process for returning student to classroom:

• Turn on Side

__________________________________________________________________________

_

• Keep Airway Open

_

__________________________________________________________________________

• Monitor Breathing

__________________________________________________________________________

SEIZURE EMERGENCY

SEIZURE EMERGENCY CALL 911

SEIZURE RESPONSE – EMERGENCY

è

A ‘Seizure Emergency’ for this student

• Convulsive (tonic-clonic) seizure lasts longer

• Call 911 after ______ minutes

is defined as:

than 5 minutes

• Contact school office / school nurse

_______________________________

• Student has repeated seizures without regaining

• Administer emergency medications, if ordered

consciousness

• Office to notify parents/guardian or

______________________________

• Student is injured, has diabetes, or is pregnant

emergency contact on ER card

• Student has a first time seizure

______________________________

• Student has breathing difficulties

Other:____________________________________

______________________________

• Student has a seizure in water

In case of disaster, a 3 day supply of medications must be provided

Emergency Medication:

Dosage & Time Given:

Common Side Effects & Special Instructions

Daily Medication:

Dosage & Time Given:

Common Side Effects & Special Instructions

DIASTAT Medication: If prescribed, go to

and download the Diastat Forms

 

Does student have a vagus Nerve Stimulator?

Yes

No If YES, provide VNS protocol.

Special Considerations and Precautions (regarding school activities, swimming, helmet use, or bus riding after seizure, etc.)

pausd

Physician Signature: _______________________________________

_____________________________________

_____

PRINTED NAME:

DATE:

This form authorizes medication to be given during school hours, on extended field trips or in the incidence of a public disaster i.e., earthquake. I consent to communication and

exchange of information between my physician and Palo Alto Unified School District to discuss and share records/conditions pertaining to the above. I understand that this information

Ed Code 49480

is confidential and may not be given to employees of other schools, public agencies or individual professionals in private practice without my consent.

This Form Must Be Renewed Annually Or With Any Change In Treatment Or Medication

Parent/Guardian Signature: ________________________________________________________________________ Date:_________________

* Ed. Code 49414.7

8/20/14