"Nm Food/Insect and Emergency Allergy Action Plan and Medication Authorization" - New Mexico

Nm Food/Insect and Emergency Allergy Action Plan and Medication Authorization is a legal document that was released by the New Mexico Department of Health - a government authority operating within New Mexico.

Form Details:

  • The latest edition currently provided by the New Mexico Department of Health;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the New Mexico Department of Health.

ADVERTISEMENT
ADVERTISEMENT

Download "Nm Food/Insect and Emergency Allergy Action Plan and Medication Authorization" - New Mexico

Download PDF

Fill PDF online

Rate (4.8 / 5) 49 votes
NM FOOD/INSECT & EMERGENCY ALLERGY ACTION PLAN and MEDICATION AUTHORIZATION
School District / School Name _________________________________________ Date __________________ School Year ______________
www.foodallergy.org
Student Name
Date of Birth
Student #
Epinephrine injector
is stored in:
*Health Care Provider Name/Title
Provider’s Office Phone / FAX #
 With Student
 Classroom
Parent/Guardian
Parent’s Phone #s
 Health Office
Emergency Contact
Contact Phone #s
 ________________
Student’s weight: ______________lbs.
Asthma:
Y
(higher risk for a severe reaction)
ES
N
O
Allergy to:
Give epinephrine immediately:
[ ] for ANY symptoms if allergen was likely eaten.
[ ] If allergen was definitely eaten, even if no symptoms are noticed.
F
:
OLLOW THIS PROTOCOL
F
ANY
SEVERE SYMPTOMS:
OR
OF THE FOLLOWING
1.
INJECT EPINEPHRINE IMMEDIATELY!
(Note time)
LUNG:
Short of breath, wheezing, repetitive cough
2
. Call 911. Request ambulance with epinephrine.
HEART:
Dizzy, faint, confused, pale, blue, weak pulse
Don’t hang up & don’t leave student
THROAT: Tight, hoarse, trouble breathing/swallowing, drooling
● Give additional medications as ordered
[Antihistamine (if ordered below)]
MOUTH: Swelling of tongue, lips
[Inhaler (Albuterol) if student has asthma]
SKIN:
Many hives over body, widespread redness over body
● Lay student flat and raise legs. If breathing is
GUT:
Nausea, repetitive vomiting, severe diarrhea, cramping
difficult or vomiting, sit up or lie on their side
● Notify School Nurse and Parent/Guardian
Other:
Feeling something bad is about to happen, anxiety,
● Notify Prescribing Provider / PCP
Confusion
● When indicated, assist student to rise slowly
OR
A combination of mild symptoms from different body areas
● Student must be transported to ER
:
1. GIVE ANTIHISTAMINE (as ordered below)
MILD ALLERGY SYMPTOMS
2. Stay with student; alert school nurse & parent/guardian
MOUTH: Itchy mouth, lips, tongue and/or throat
3. Watch student closely for changes
SKIN:
A few hives, itchy skin
- If symptoms worsen, GIVE EPINEPHRINE
NOSE:
Itchy/runny nose, sneezing
- For mild symptoms from more than one body area -
GIVE EPINEPRHINE (see above).
GUT:
Mild nausea/discomfort
T
. A
!!
HE SEVERITY OF SYMPTOMS CAN QUICKLY CHANGE
LL SYMPTOMS OF ANAPHYLAXIS CAN POTENTIALLY PROGRESS TO A LIFE THREATENING SITUATION
Epinephrine (0.15mg) inject intramuscularly
Epinephrine (0.3mg) inject intramuscularly
Epinephrine
Epi Pen
Auvi Q
Adrenaclick
Epi Pen
Auvi Q
Adrenaclick
A second dose of epinephrine can be given 5 minutes or more after the first if symptoms persist or recur.
Note: If School Nurse is not available,
Antihistamine
Other _____________
Benadryl/Diphenhydramine
Do not depend on
the above treatment plan may be
Dose: _________mg
Dose:
mg.
antihistamines or inhalers.
Route:
provided by trained school personnel
When in doubt, give
Route: PO
epinephrine and call 911.
for any anaphylaxis symptoms.
MUST BE COMPLETED BY PARENT AND AUTHORIZED HEALTH CARE PROVIDER
Prescriber’s Signature
*
: __________________________________ Date: ____________
School Nurse:
Printed Name: ___________________________________ Phone: _________________
I have reviewed this order and
completed the Allergy Emergency
at school
Student is able to carry and self-administer his/her medication
Yes
No
Care Plan and have trained
:
school personnel.
Parent/Guardian Consent
I have received, reviewed and understand the above information. I approve of this Allergy
Action Plan. I give my permission for the school nurse and trained school personnel to follow this plan, administer
__________________________
medication(s), and contact my provider, if necessary. I assume full responsibility for providing the school with the prescribed
Signature / Date
medications. I give my permission for the school to share the above information with school staff that need to know about
my child’s condition.
Medication Expires on:
Parent/Guardian Signature
Date:
: _______________________________________
__________________
__________________________
I confirm my child is capable to carry and administer above medication
Yes
No
Potential for altered respiratory status/anaphylaxis
Allergy Action Plan
Goal: Patent Airway
NM FOOD/INSECT & EMERGENCY ALLERGY ACTION PLAN and MEDICATION AUTHORIZATION
School District / School Name _________________________________________ Date __________________ School Year ______________
www.foodallergy.org
Student Name
Date of Birth
Student #
Epinephrine injector
is stored in:
*Health Care Provider Name/Title
Provider’s Office Phone / FAX #
 With Student
 Classroom
Parent/Guardian
Parent’s Phone #s
 Health Office
Emergency Contact
Contact Phone #s
 ________________
Student’s weight: ______________lbs.
Asthma:
Y
(higher risk for a severe reaction)
ES
N
O
Allergy to:
Give epinephrine immediately:
[ ] for ANY symptoms if allergen was likely eaten.
[ ] If allergen was definitely eaten, even if no symptoms are noticed.
F
:
OLLOW THIS PROTOCOL
F
ANY
SEVERE SYMPTOMS:
OR
OF THE FOLLOWING
1.
INJECT EPINEPHRINE IMMEDIATELY!
(Note time)
LUNG:
Short of breath, wheezing, repetitive cough
2
. Call 911. Request ambulance with epinephrine.
HEART:
Dizzy, faint, confused, pale, blue, weak pulse
Don’t hang up & don’t leave student
THROAT: Tight, hoarse, trouble breathing/swallowing, drooling
● Give additional medications as ordered
[Antihistamine (if ordered below)]
MOUTH: Swelling of tongue, lips
[Inhaler (Albuterol) if student has asthma]
SKIN:
Many hives over body, widespread redness over body
● Lay student flat and raise legs. If breathing is
GUT:
Nausea, repetitive vomiting, severe diarrhea, cramping
difficult or vomiting, sit up or lie on their side
● Notify School Nurse and Parent/Guardian
Other:
Feeling something bad is about to happen, anxiety,
● Notify Prescribing Provider / PCP
Confusion
● When indicated, assist student to rise slowly
OR
A combination of mild symptoms from different body areas
● Student must be transported to ER
:
1. GIVE ANTIHISTAMINE (as ordered below)
MILD ALLERGY SYMPTOMS
2. Stay with student; alert school nurse & parent/guardian
MOUTH: Itchy mouth, lips, tongue and/or throat
3. Watch student closely for changes
SKIN:
A few hives, itchy skin
- If symptoms worsen, GIVE EPINEPHRINE
NOSE:
Itchy/runny nose, sneezing
- For mild symptoms from more than one body area -
GIVE EPINEPRHINE (see above).
GUT:
Mild nausea/discomfort
T
. A
!!
HE SEVERITY OF SYMPTOMS CAN QUICKLY CHANGE
LL SYMPTOMS OF ANAPHYLAXIS CAN POTENTIALLY PROGRESS TO A LIFE THREATENING SITUATION
Epinephrine (0.15mg) inject intramuscularly
Epinephrine (0.3mg) inject intramuscularly
Epinephrine
Epi Pen
Auvi Q
Adrenaclick
Epi Pen
Auvi Q
Adrenaclick
A second dose of epinephrine can be given 5 minutes or more after the first if symptoms persist or recur.
Note: If School Nurse is not available,
Antihistamine
Other _____________
Benadryl/Diphenhydramine
Do not depend on
the above treatment plan may be
Dose: _________mg
Dose:
mg.
antihistamines or inhalers.
Route:
provided by trained school personnel
When in doubt, give
Route: PO
epinephrine and call 911.
for any anaphylaxis symptoms.
MUST BE COMPLETED BY PARENT AND AUTHORIZED HEALTH CARE PROVIDER
Prescriber’s Signature
*
: __________________________________ Date: ____________
School Nurse:
Printed Name: ___________________________________ Phone: _________________
I have reviewed this order and
completed the Allergy Emergency
at school
Student is able to carry and self-administer his/her medication
Yes
No
Care Plan and have trained
:
school personnel.
Parent/Guardian Consent
I have received, reviewed and understand the above information. I approve of this Allergy
Action Plan. I give my permission for the school nurse and trained school personnel to follow this plan, administer
__________________________
medication(s), and contact my provider, if necessary. I assume full responsibility for providing the school with the prescribed
Signature / Date
medications. I give my permission for the school to share the above information with school staff that need to know about
my child’s condition.
Medication Expires on:
Parent/Guardian Signature
Date:
: _______________________________________
__________________
__________________________
I confirm my child is capable to carry and administer above medication
Yes
No
Potential for altered respiratory status/anaphylaxis
Allergy Action Plan
Goal: Patent Airway