Sickle Cell Healthcare Plan Template printable pdf download

HIGH MEADOWS SCHOOL YEAR _____ - _____

SICKLE CELL HEALTHCARE PLAN

Student:

DOB:

Grade/HR teacher initials:

Goals: Prevent/Decrease Sickle Cell Events

1. Maintain adequate hydration, carry water bottle

2. Exercise based on tolerance

3. Avoid extremes in hot/cold temperatures, dress appropriate for weather

4. Staff awareness of signs/symptoms and treatments of sickle cell events.

PHYSICIAN TO COMPLETE TREATMENT PLAN AND SIGN:

CIRCLE SYMPTOMS THAT CHILD MAY PRESENT DURING A SICKLE CELL CRISIS AND

NOTE ANY INTERVENTIONS REQUESTED BELOW

Pain: Locations________________________________________________

Fever: What temperature do we call parent? _________________________

Fatigue/Weakness

Pale or Jaundice colored skin

Cough / Shortness of Breath / Increased heart rate

Vomiting/Diarrhea

Unusual behavior/ Refusal to eat/drink

TREATING PHYSICIAN’S SIGNATURE_________________________________DATE: ___________

*PLEASE NOTE: Parent must provide any medication prescribed by the physician. Any necessary medication is sent on

all field trips and is kept by the teacher in charge of that particular student.

(CALL FIRST) PARENT/GUARDIAN

(CALL SECOND) PARENT/GUARDIAN

NAME: _______________________________________ NAME: __________________________________________

PHONE: ______________________________________ PHONE: _________________________________________

EMERGENCY CONTACT: _______________________

EMERGENCY CONTACT: _____________________________

PHONE: _____________________________________ PHONE: ___________________________________________

PHYSICIAN TREATING CONDITION

_________________________________PH#: _______________

(printed name):

Possible Symptoms

School Nurse Interventions

1. Fatigue

A. Exercise based on tolerance, Rest as needed

2. Pain: mild to moderate arms

A. Stop activity and rest

legs/chest/abdomen

B. Give fluids/ carry water bottle

Warm compresses to site if helpful

Medication per MD request & parental consent:

Medication___________________________

Use coping strategies, divert attention, be calming and

reassuring ; Loosen tight or restrictive clothes

Reevaluate pain after comfort measures in place.

3. Severe Pain, swollen and painful

Call parent, seek immediate medical attention-911

Abdomen, pallor, lethargy, possible Shock, vomiting

Other:______________________________

Or diarrhea

Fever

Call parent - Over 101 degrees, go home

Give fluids - Keep in clinic until they go home

PARENT SIGNATURE:

DATE:

Sickle Cell Healthcare Plan Template

Related Articles

Related forms

Related Categories