Allergy Anaphylaxis Action Plan - 2015
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1
2A
/A
C
P
LLERGY
NAPHYLAXIS
ARE
LAN
Name _________________________________ Birthdate _________ Teacher __________________________
School Nurse________________________________ Phone __________________Fax _____________________
Healthcare Provider __________________________ Preferred Hospital _______________
No Yes-Higher risk for severe reaction
H
A
:
ISTORY OF
STHMA
Student
A
:
(check appropriate) To be completed by Healthcare Provider
Photo
LLERGY
Foods (list):
Medications (list):
Latex:
Type I (anaphylaxis)
Type IV (contact dermatitis)
Stinging Insects (list):
Other (list):
R
& T
:
ECOGNITION
REATMENT
Chart to be completed by Healthcare Provider ONLY
Give CHECKED Medication
If food ingested or contact w/ allergen occurs:
Epinephrine
Antihistamine
No symptoms noted
Observe for other symptoms
Itching, tingling, or swelling of lips, tongue, mouth
Mouth
Skin
Hives, itchy rash, swelling of the face or extremities
Gut+
Nausea, abdominal cramps, vomiting, diarrhea
Tightening of throat, hoarseness, hacking cough
Throat+
Lung+
Shortness of breath, repetitive coughing, wheezing
Thready pulse, low BP, fainting, pale, blueness
Heart+
Disorientation, dizziness, loss of consciousness
Neuro+
If reaction is progressing (several of the above areas affected), GIVE:
The severity of symptoms can quickly change. + = Potentially life-threatening.
D
:
OSAGE
0.3 mg OR 0.15 mg
Epinephrine: Inject into outer thigh (through clothing)
Antihistamine:
Loratadine _____mg
Cetirizine _____mg
Diphenhydramine _____mg
(Liquid or melts or depends which is available). To be given by mouth only if able to swallow.
Other:
This child has received instruction in the proper use of the Auto-injector: EpiPen® or Auvi-Q® or ___________
(circle one). It is my professional opinion that this student SHOULD be allowed to carry and use the auto-injector
independently. The child knows when to request antihistamine and has been advised to inform a responsible adult if
the auto-injector is self-administered.
It is my professional opinion (HCP) that this student SHOULD NOT carry an auto-injector.
:______________________________________
This child has special needs and the following instructions apply
__________________________________________________________________________________________
Healthcare Provider Signature __________________________Phone: ________________ Date ______________
E
P
:
MERGENCY
ROTOCOL
911. State that an allergic reaction has been treated, and additional epinephrine may be needed.
Call
1. Call parents/guardian to notify of reaction, treatment and student's health status.
2. Treat for shock. Prepare to do CPR.
Anchorage School District
Nursing & Health Services; Adapted from the Asthma & Allergy Foundation of America, Alaska Chapter
Page 1 of 2
NUR # 0502
Rev 10/2015
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