Anaphylaxis Severe Allergic Reaction

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					                            Anaphylaxis (Severe Allergic) Reaction
                                    Anson Independent School District
                                             Health Services Department


Parent/Guardian(s)-

      According to HB 1688, a student with asthma is entitled to possess and self administer prescription asthma or anaphylaxis
      medicine while on school property or at a school-related event or activity, with permission from parents and physicians. In
      an effort to meet student needs and still maintain a safe environment with regard to medications in the school setting, the
      following procedures have been developed and incorporated into school health services program.



In order for the Anson ISD Health Department and/or a student to administer anaphylaxis
medications at school, the Serious Allergy – Anaphylaxis Reaction Action Plan and the
Parent/Physician Authorization for Self-Administration of Asthma or Anaphylaxis Medication by a
Student forms (attached) must be completed as follows:
          1. Completed and signed by student’s physician
          2. Parent read and signature
          3. Return to nurse’s office

Each student that has an asthma action plan must also have an Emergency Contact Information
and Consent (attached) on file in the nurse’s office.
         1. This information is to be provided by the parent/guardian, including the
             parent/guardian(s) signature.

After the Serious Allergy – Anaphylaxis Reaction Action Plan, Emergency Contact Information and
Consent and the Parent/Physician Authorization for Self-Administration of Anaphylaxis Medication
by a Student forms have been completed, please return all documents to the nurse’s office.
All medications and supplies may also be delivered once documents are on file.

Medications will need to be in original container with prescription label attached. Medications, and
supplies need to be placed in storage (Ziplock® type) bag with student’s name placed on outside.
All medications and supplies will need to be picked up on or before the final day of class. All
unclaimed medications will be discarded at the end of the school year. There will be NO
medications kept in the clinic through the summer months.

Should you have any questions, I can be reached Monday-Friday 8am-3pm at 823-4475. I
appreciate your help in providing the necessary information needed to provide the best possible
care to your child.

Thank you,
Michelle Huffaker, RN
Anson ISD Health Services Department
                                         Serious Allergy – Anaphylaxis Reaction
                                                 Emergency Action Plan
                      (To be completed and signed by both parent/guardian and physician)

Student’s Name: ________________________________________ Date of Birth: ________________

Allergy To: □ Bees □ Wasp □ Hornet        Type of Reaction □ Difficulty Breathing □ Rash □ Hives
□ Other Insect(s) List: ________________ Type of Reaction □ Difficulty Breathing □ Rash □ Hive
□ Food(s) List: ______________________ Type of Reaction □ Difficulty Breathing □ Rash □ Hives
Has Student been diagnosed with Asthma? □ Yes □ No Medication given at school: ______________

 Symptoms                                                                    Emergency Treatment to be completed by Physician
 Mild Symptoms (Local reaction)                                               »IF STUDENT HAS MILD SYMPTOMS OR INGESTED IS
 * Mild skin reactions                              Hives/Swelling only       SUSPECTED:          CALL 911
                                                      in the areas of
                                                     allergen contact.                 Note time _____________ and stay with student
                                                                                       Watch closely for serious symptoms
 Students with an Epi-pen or history of anaphylaxis must go home                       Give _______________________ as ordered by
  With parental supervision for the remainder of the school day.                        physician
                                                                                       Call parent or emergency contact
        SYMPTOMS CAN BECOME MORE SERIOUS VERY QUICKLY                                  Stay with student until parent or EMS arrives
               OR OVER THE NEXT SEVERAL HOURS.                                         Call school nurse



                       DO NOT HESITATE TO CALL 911 OR TO GIVE EMERGENCY MEDICATION(S)

            SERIOUS SYMPTOMS (Systemic Reaction):                              IF STUDENT HAS ANY SERIOUS SYMPTOMS:
            Skin      widespread hives and flushing, widespread                       Note time _____________ and stay with student
                       swelling                                                        Give ___________________ as ordered by physician
            Mouth    swelling of the tongue                                           Administer Epi-pen. Follow directions on injection
            Throat    itching, or a sense of tightness of the throat,                  Device as trained. Note time given ______________
                       Hoarseness, hacking cough                                       Call 911: ask for Advance Life Support for an
            Gut      vomiting, nausea, cramps, diarrhea                                Allergic reaction
            Lungs    repetitive coughing, wheezing, trouble breathing                 Call parent or emergency contacts
            Heart    rapid heart rate, lightheadness, dizziness, loss of              Call school nurse
                       consciousness


**********************************************************************************
                             Section below to be filled out by Parent/Guardian
    A separate current medication permission slip must be completed if medication is part of this plan.
    This “Emergency Action Plan” will be available to staff who work closely with your child.
    I understand that if any changes are needed on this Emergency Action Plan, it is the parent’s responsibility to
     contact the school nurse.

                PLEASE COMPLETE THIS SECTION IF YOUR CHILD HAS A SEVERE FOOD ALLERGY
 Note: Meals from home provide the safest food option at school.

 □ Check here if student will eat ANY school provided meals in the entire 2010-2011 school year.   If so, the “special Dietary Needs Application”
               MUST be completed.

 FOODS TO OMIT:
 ___________________________________________________________________________________________________________________
 ___________________________________________________________________________________________________________________


           This Emergency Action Plan must be signed by both parent/guardian and physician
           My signature below shows I reviewed and agree with this plan.

___________________________________ ______________                          __________________________________ ____________
Parent Signature                     Date                                   Physician Signature                 Date

___________________________________ ______________                           _______________________________________________
School Nurse Signature               Date                                    Physician’s Name Printed
                       Emergency Contact Information and Consent
                           Anson Independent School District
                                   (To be completed by parent/guardian)

Student Name: ____________________________________ Teacher _____________

Student Food Allergies: _________________________________________________
                        _________________________________________________
                        _________________________________________________

Student Medication Allergies: ____________________________________________
                              ____________________________________________
                              ____________________________________________

Grade: __________             Male: ___ Female: ___ Date of Birth: ___________________

Address: ____________________________                               Home Phone: __________________
         ____________________________                               Cell Phone: ___________________
         ____________________________                               Emergency No.: ________________

Father’s Name: _____________________________ Work Phone: ______________ Cell Phone _______________

Mother’s Name: ____________________________ Work Phone: _______________ Cell Phone _______________




In case parents can not be reached at time of emergency, please call:

Name: _________________________________ Phone: _______________________
Relationship to student: _________________ Phone: ________________________


Unfortunately, there is always the possibility of an accident occurring to a student at school or while participating in
an after-school activity. In case an accident should occur, the school and/or the UIL does not assume
responsibility. Nevertheless, if an accident should occur, a discretionary judgment will be made by a school
representative in regard to the student’s need for immediate care and treatment. Therefore, I do herby request,
authorize, and consent to such care and treatment as may be given to the said student by and physician, trainer,
nurse or school representative. As well, I do hereby agree to indemnify and save harmless the school and any
school representative from any claim by any person whomsoever on account of such care and treatment of the said
student.

Between this date and the end of the school year, illness or injury could occur that may limit the student’s
participation, I agree to notify the school authorities of such illness or injury.

________________________________                                 _________________________
Signature of Parent/Guardian                                     Date

______________________________                                   _______________________
Signature of Parent/Guardian                                     Date
  Parent/Physician Authorization for Self-Administration of Anaphylaxis Medication
                                    By a Student
              (To be completed and signed by both parent/guardian and physician)


                                            Parent Authorization
I have reviewed the attached guidelines and procedures for Self-Administration of Prescription Asthma or Anaphylaxis
Medication by Students; discussed them with my child; and request that my child be able to possess and self-
administer his/her prescription asthma or anaphylaxis medication while on school property or at a school-related
event or activity. I understand that the asthma or anaphylaxis medication must be prescribed for my child as
indicated on the prescription label, which must be affixed to the medication container (inhaler canister or packaging
box). I release the school district and employees of any liability arising from self-administration.

_____________________________________________________                 ___________________________
Parent/Guardian Signature                                              Date




                                          Physician Authorization

The medical history and my examination of _______________________________________________,
                                                                  Students Name
indicates that he/she does have asthma or anaphylaxis. The student has been educated and is knowledgeable about
his/her asthma or anaphylaxis and can properly self-administer the prescribed medication and determine its
effectiveness.

Name of Medication: __________________________________________________________________

Purpose of Medication: _________________________________________________________________

Prescribed Dosage: ____________________________________________________________________

Times at which or circumstances under which the medicine may be administered:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

Period of time for which the medicine has been prescribed:
                              □ Long Term (chronic condition)
                              □ Short Term and should be discontinued by ________________________
                                                                                     Date

________________________________________              ________________________________________
            Physician’s Printed Name                                 Physician’s Signature

              Office Telephone Number: ______________________________________

				
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posted:12/4/2011
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