"Colorado Allergy and Anaphylaxis Emergency Care Plan and Medication Orders" - Colorado

Colorado Allergy and Anaphylaxis Emergency Care Plan and Medication Orders is a legal document that was released by the Colorado Department of Education - a government authority operating within Colorado.

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Colorado Allergy and Anaphylaxis Emergency Care Plan and Medication Orders
Student’s Name: _____________________________________D.O.B. __________ Grade: ____________
Place child’s
School: ____________________________________________ Teacher: ___________________________
photo here
ALLERGY TO:
____________
HISTORY:
_______________________________________________________________________
______________________________________________________________________________________
Asthma:
YES (higher risk for severe reaction) – refer to their asthma care plan
◊ STEP 1: TREATMENT
NO
1. INJECT EPINEPHRINE IMMEDIATELY
2. Call 911
Ask for ambulance with epinephrine
Tell EMS when epinephrine was given
SEVERE SYMPTOMS: Any of the following:
3. Stay with child and
LUNG:
Short of breath, wheeze, repetitive cough
Call parent/guardian and school nurse
THROAT: Tight, hoarse, trouble breathing/swallowing
If symptoms don't improve or worsen
MOUTH: Swelling of the tongue and/or lips
give second dose of epi if available as
HEART:
Pale, blue, faint, weak pulse, dizzy
instructed below
SKIN:
Many hives over body, widespread redness
Monitor student; keep them lying down.
GUT:
Vomiting or diarrhea (if severe or combined
If vomiting or difficulty breathing, put
with other symptoms
student on side
OTHER:
Feeling something bad is about to happen,
Give other medicine, if prescribed. (see below for
Confusion, agitation
orders) Do not use other medicine in place of
epinphrine. USE EPINEPHRINE
1. Stay with child and
MILD SYMPTOMS ONLY:
Alert parent and school nurse
NOSE:
Itchy, runny nose, sneezing
Give antihistamine (if prescribed)
2. If two or more mild symptoms present or
SKIN:
A few hives, mild itch
symptoms progress GIVE EPINEPHRINE
GUT:
Mild nausea/discomfort
and follow directions in above box
DOSAGE:
0.3 mg
0.15 mg
Epinephrine
inject intramuscularly using auto injector (check one):
:
If symptoms do not improve ____ minutes or more, or symptoms return, 2
nd
dose of epinephrine should be given if available
Antihistamine: (brand and dose)_______________________________________________________________
Asthma Rescue Inhaler (brand and dose)
Student has been instructed and is capable of carrying and self-administering own medication.
Yes
No
Provider (print) __________________________________________________Phone Number: ______________
Provider’s Signature: _____________________________________________ Date: _______________________
◊ STEP 2: EMERGENCY CALLS ◊
1. If epinephrine given, call 911. State that an anaphylactic reaction has been treated and additional
epinephrine, oxygen, or other medications may be needed.
2. Parent: ________________________________ Phone Number: ____________________________
3. Emergency contacts: Name/Relationship
Phone Number(s)
a. _______________________________________1) _______________ 2) ________________
b. _______________________________________ 1) ______________ 2) ________________
DO NOT HESITATE TO ADMINISTER EMERGENCY MEDICATIONS
I give permission for school personnel to share this information, follow this plan, administer medication and care for my child and, if necessary,
contact our health care provider. I assume full responsibility for providing the school with prescribed medication and delivery/monitoring devices
and release the school and personnel from any liability in compliance with their Board of Education policies.
Parent/Guardian’s Signature: ______________________________________________
Date: _______________________
School Nurse: ___________________________________________________________
Date: ________________________
Colorado Allergy and Anaphylaxis Emergency Care Plan and Medication Orders
Student’s Name: _____________________________________D.O.B. __________ Grade: ____________
Place child’s
School: ____________________________________________ Teacher: ___________________________
photo here
ALLERGY TO:
____________
HISTORY:
_______________________________________________________________________
______________________________________________________________________________________
Asthma:
YES (higher risk for severe reaction) – refer to their asthma care plan
◊ STEP 1: TREATMENT
NO
1. INJECT EPINEPHRINE IMMEDIATELY
2. Call 911
Ask for ambulance with epinephrine
Tell EMS when epinephrine was given
SEVERE SYMPTOMS: Any of the following:
3. Stay with child and
LUNG:
Short of breath, wheeze, repetitive cough
Call parent/guardian and school nurse
THROAT: Tight, hoarse, trouble breathing/swallowing
If symptoms don't improve or worsen
MOUTH: Swelling of the tongue and/or lips
give second dose of epi if available as
HEART:
Pale, blue, faint, weak pulse, dizzy
instructed below
SKIN:
Many hives over body, widespread redness
Monitor student; keep them lying down.
GUT:
Vomiting or diarrhea (if severe or combined
If vomiting or difficulty breathing, put
with other symptoms
student on side
OTHER:
Feeling something bad is about to happen,
Give other medicine, if prescribed. (see below for
Confusion, agitation
orders) Do not use other medicine in place of
epinphrine. USE EPINEPHRINE
1. Stay with child and
MILD SYMPTOMS ONLY:
Alert parent and school nurse
NOSE:
Itchy, runny nose, sneezing
Give antihistamine (if prescribed)
2. If two or more mild symptoms present or
SKIN:
A few hives, mild itch
symptoms progress GIVE EPINEPHRINE
GUT:
Mild nausea/discomfort
and follow directions in above box
DOSAGE:
0.3 mg
0.15 mg
Epinephrine
inject intramuscularly using auto injector (check one):
:
If symptoms do not improve ____ minutes or more, or symptoms return, 2
nd
dose of epinephrine should be given if available
Antihistamine: (brand and dose)_______________________________________________________________
Asthma Rescue Inhaler (brand and dose)
Student has been instructed and is capable of carrying and self-administering own medication.
Yes
No
Provider (print) __________________________________________________Phone Number: ______________
Provider’s Signature: _____________________________________________ Date: _______________________
◊ STEP 2: EMERGENCY CALLS ◊
1. If epinephrine given, call 911. State that an anaphylactic reaction has been treated and additional
epinephrine, oxygen, or other medications may be needed.
2. Parent: ________________________________ Phone Number: ____________________________
3. Emergency contacts: Name/Relationship
Phone Number(s)
a. _______________________________________1) _______________ 2) ________________
b. _______________________________________ 1) ______________ 2) ________________
DO NOT HESITATE TO ADMINISTER EMERGENCY MEDICATIONS
I give permission for school personnel to share this information, follow this plan, administer medication and care for my child and, if necessary,
contact our health care provider. I assume full responsibility for providing the school with prescribed medication and delivery/monitoring devices
and release the school and personnel from any liability in compliance with their Board of Education policies.
Parent/Guardian’s Signature: ______________________________________________
Date: _______________________
School Nurse: ___________________________________________________________
Date: ________________________
Student Name: ___________________________________________________ DOB: ___________________________________
Staff trained and delegated to administer emergency medications in this plan:
1.___________________________________________
Room _____________________________
2.___________________________________________
Room _____________________________
3.___________________________________________
Room _____________________________
Yes
No
Self-carry contract on file:
Expiration date of epinephrine auto injector: ____________________________________
Keep the child lying on their back. If the child vomits or has trouble breathing, place child on his/her side.
If this conditions warrents meal accomodations from food service, please complete the form for dietary disabilitiy if required by
district policy.
Additional information
:_______________________________________________________________________________________
_____________________________________________________________________________________________
_________
_____________________________________________________________________________________________
_________
____________________________________________________________________________________________________________
Adopted from the Allergy and Anaphylaxis Emergency Plan provided by the American Academy of Pediatrics, 2017
January 2018
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