ࡱ> yx{M -Rbjbj== sWWBMl@@@$d????dX@,d-jACCCCiKtMD!O$ ҟ@OIiKOOҟwTCCwTwTwTOC@CwTOwT wTah@HCA x'ZZ\d8?Q|6Hd0-IwTIHwTddSTUDENT ALLERGY PREVENTION AND RESPONSE (District Keeps Epinephrine Premeasured Auto-Injection Devices on Hand) Staff Training Procedures Staff training procedures regarding food allergies and anaphylactic reactions will be held annually at the beginning of each school year and as needed for new employees. As per Windsors Student Allergy Prevention and Response policy, the staff will be trained on: signs and symptoms of an allergic reaction the use of an Epi-Pen auto-injector allergy prevention awareness emergency response Anaphylaxis refers to a severe allergic reaction. An allergic reaction is an immune system response to a substance that itself is not harmful but that the body interprets as being harmful. Allergic reactions range from mild to severe, even life-threatening. Foods that most commonly cause an allergic reaction are peanuts, tree nuts, shellfish, milk, wheat, soy, fish and eggs. These severe allergic reactions can occur within minutes of ingestion or a reaction can be delayed for up to two hours. At present there is no cure for food allergies and strict avoidance is the key to preventing reactions. Exposure may occur by eating the food or food contact. SIGNS OF AN ALLERGIC REACTIONMOUTHItching and swelling of the lips, tongue or mouthTHROATItching and/or sense of tightness in the throat, hoarseness, hacking cough, and swelling of tongue and throat.SKINHives, itchy rash, and/or swelling about the face or extremitiesSTOMACHNausea, abdominal cramps, vomiting, and/or diarrheaLUNGShortness of breath, repetitive coughing, and/or wheezingHEARTThready pulse, one feels like passing outThe severity of symptoms can quickly change. All above symptoms can potentially progress to a life-threatening situation! If you notice ANY symptoms or if they are exposed, send or contact the nurse immediately. * The bolded symptoms are the most common. DIRECTIONS FOR ADMINISTERING EPIPEN AND EPIPEN JR. Pull off activation cap. Hold back tip near outer thigh (always apply to thigh). Swing and jab firmly into outer thigh until auto-injector mechanism functions. Hold in place and count to 10. The Epi-Pen unit would then be removed and taken with you to the Emergency Room. Massage the injection area for 10 seconds. PREVENTION Training is provided to staff on the signs and symptoms of a severe allergic reaction as provided in the students Section 504 plan or IHP/AAP. Staff should be aware of and implement the emergency plan, if a reaction is suspected. In collaboration with the teacher, nurse and parents/guardians of the allergic student, a classroom plan regarding the management of food in the classroom will be developed. The classroom teacher will notify parents by written communication of any school-related activity that requires the use of food in advance of the project or activity (i.e. classroom parties, classroom rewards). Encourage proper hand washing before and after eating. All staff should be responsible for personal food consumption within the school setting with consideration to students with life-threatening food allergies. EMERGENCY RESPONSE If you are aware of a students exposure to a possible food allergen or notice ANY signs of an allergic reaction, contact the nurse immediately. In the event a student has an allergic reaction at school and the nurse is unavailable, call 911 and administer emergency medication (i.e. Epi-Pen) as indicated by the students Section 504 plan or IHP. When in doubt, it is better to give the emergency medication than to take the chance of the situation becoming life threatening. The school principal and parent/guardian should be notified as soon as feasible. WINDSOR C-1 SCHOOL DISTRICT INDIVIDUAL HEALTHCARE PLAN SCHOOL NURSE CARE PLAN STUDENT:DOB:DATE:GRAEDE/TEACHER:HOME PHONE:REVIEW DATES:PARENTS:EMERGENCY #:SIGNATURES/INITIALS:PHYSICIAN:DATES OF PARENT CONTACT:HOSPITAL PREFERENCE:MEDICAL DIAGNOSIS/CONDITION: SEVERE ALLERGIC REACTIONMEDICATIONS/EQUIPMENT:  FORMCHECKBOX  Severe Allergy Plan attached  FORMCHECKBOX  Carries EPI-PEN Possible triggers: (check all that apply)  FORMCHECKBOX  Tree nuts  FORMCHECKBOX  Peanuts  FORMCHECKBOX  Eggs  FORMCHECKBOX  Medication  FORMCHECKBOX  Insect bites or stings Type: ______  FORMCHECKBOX  Other: _______________________  Usual signs and symptoms: (Check all that apply)  FORMCHECKBOX  Wheezing  FORMCHECKBOX  Shock  FORMCHECKBOX  Difficulty breathing/talking  FORMCHECKBOX  Loss of consciousness  FORMCHECKBOX  Chest pain or tightness  FORMCHECKBOX  Other __________________________  FORMCHECKBOX  Itching  FORMCHECKBOX  Hives  FORMCHECKBOX  Swelling of face, throat, tongue or eyes NURSING DIAGNOSISGOALSINTERVENTIONSEVALUATION DATES Potential life-threatening condition due to allergic reaction.  Decrease number and severity of allergic reactions. Quickly recognize signs of severe allergic reaction. Stabilize after exposure. 1. Minimize exposure to triggers. Inform staff members of potential triggers and strive to eliminate them. 2. Assess reaction to exposure. Notify parent. Monitor A airway B breathing C circulation. CALL 911 IF SEVERE REACTION AND/OR EPI-PEN IS USED. 3. Assess O2 sat. 4. Administer prescribed medication after exposure: Name: Dose:  FORMCHECKBOX  May repeat in 5 minutes. Use Epi-pen per standing order, if needed.  FORMCHECKBOX  Take students Epi-pen on filed trip. Train at least 1 staff member going on field trip using trainer pen. 5. Other:  Yearly, after hospitalization, and as needed. Date Initials  Medical Statement for Student Requiring Special Meals Name of Student:School District:Birth Date:School Attended:Parent Name:Telephone:Telephone: For Physicians UseIdentify and describe disability, or medical condition, including allergies that require the student to have a special diet. Describe the major life activities affected by the students disability (see back of form). _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Diet Prescription (check all that apply):  FORMCHECKBOX  Diabetic (include calorie level or attach meal plan)  FORMCHECKBOX  Modified Texture and/or Liquids  FORMCHECKBOX  Reduced Calorie  FORMCHECKBOX  Food Allergy (describe): ________________________________________  FORMCHECKBOX  Increased Calorie  FORMCHECKBOX  Other (describe): ______________________________________________ Food Omitted and Substitutions: Use space to list specific food(s) to be omitted and food(s) that may be substituted. You may attach an additional sheet if necessary. OMITTED FOODS SUBSTITUTIONS _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ Indicate Texture:  FORMCHECKBOX  Regular  FORMCHECKBOX  Chopped  FORMCHECKBOX  Ground  FORMCHECKBOX  Pureed Indicate thickness of liquids:  FORMCHECKBOX  Regular  FORMCHECKBOX  Nectar  FORMCHECKBOX  Honey  FORMCHECKBOX  Pudding  FORMCHECKBOX  Special Feeding Equipment: __________________________________________________________ Additional Comments: ___________________________________________________________________ I certify that above named student needs special school meals as described above, due to the students disability or chronic medical condition. __________________________________ ____________________________ ______________________ Physicians Signature Telephone Number Date __________________________________ ____________________________ ______________________ Signature of Preparer or Other Contact Telephone Number Date  I hereby give my permission for the school staff to follow the above stated nutrition plan. ______________________________________________________ _______________________________ Parent/Guardian Date  United States Department of Agriculture Food and Nutrition Service Instruction 783-2 7 CFR PART15b Handicapped person means any person who has a physical or mental impairment which substantially limits one or more major life activities, has record of such an impairment, or is regarded as having such an impairment. Physical or mental impairment means (1) any physiological disorder or condition, cosmetic disfiguration, or anatomical loss affecting one or more of the following body systems: Neurological, musculoskeletal, special sense organs, respiratory, including speech organs, cardiovascular, reproductive, digestive, genitourinary, hemic and lymphatic skin, and endocrine or (2) any mental or psychological disorder, such as mental retardation, organic brain syndrome, emotional or mental illness, and specific learning disabilities. The term physical or mental impairment includes, but is not limited to, such diseases and conditions as orthopedic, visual, speech, and hearing impairments; cerebral palsy, epilepsy, muscular dystrophy, multiple sclerosis, cancer, heart disease, diabetes, mental retardation, emotional illness, drug addiction, and alcoholism. Major life activities means functions such as caring for ones self, performing manual tasks, walking, seeing, hearing, speaking, breathing, learning, and working. FILE: JHCF-AF1 Critical STUDENT ALLERGY PREVENTION AND RESPONSE (Allergy Action Plan Physician Statement) Allergy to: ______________________________________________________________________________ Student: ___________________________ DOB: ____________ GR: __________ Teacher: _____________ Does student have history of asthma?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Signs of an allergic reaction specific to your child: _______________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ For Minor Reaction (Check all that apply.)  FORMCHECKBOX  1. If symptoms are: ______________________________________________________________, give (medication, dose, route) ___________________________________________________________.  FORMCHECKBOX  2. Call emergency contacts below.  FORMCHECKBOX  3. Call physician below for further directions. For Major Reaction (Check all that apply.)  FORMCHECKBOX  1. If symptoms are: ______________________________________________________________, give (medication, dose, route) _______________________________________________IMMEDIATELY.  FORMCHECKBOX  2. Call EMS.  FORMCHECKBOX  3. Call emergency contacts below.  FORMCHECKBOX  4. Call physician below for further directions. DO NOT HESITATE TO CALL EMS Additional information that you want the school to consider pertaining to your childs allergies: _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ Physicians Signature: ________________________ Parent Signature: _____________________________ Date: _______________ Phone: _______________ Date: _______________ Phone: _________________ EMERGENCY CONTACTS 1. _____________________________________________ Relation: _______________________________________ Phone: ________________________________________ Phone: ________________________________________ 2. _____________________________________________ Relation: _______________________________________ Phone: ________________________________________ Phone: ________________________________________ FILE: JHCF-AF1 Critical TRAINED STAFF MEMBERS TO ADMINISTER PERMEASURED EPINEPHRINE (If any, in addition to any building school nurse) 1. ___________________________________________ Room: _______________________________________ 2. ___________________________________________ Room: _______________________________________ ( ( ( ( ( ( ( Note: The reader is encouraged to review policies and/or procedures for related information in this administrative area. Implemented: 02/23/2011 Revised: 04/15/2011 Windsor C-1 School District, Imperial, Missouri  FILE: JHCF-AF4 Critical STUDENT ALLERGY PREVENTION AND RESPONSE (Epinephrine Medication Self-Administration) Student Name: ________________________________________ Grade: _______ School Year: ________________ The Missouri Safe Schools Act of 1996 provides for students to carry self-administer lifesaving medications when the following criteria are met: A licensed physician prescribed or ordered the medication for use by the child and instructed such child in the correct responsible use of the medication. The child has demonstrated to the childs licensed physician or the licensed physicians designee, and the school nurse, if available, the skill level necessary to use the medication and any device necessary to administer such medication prescribed or ordered. The childs physician has approved and signed a written treatment plan for managing asthma or anaphylaxis episodes of the child and for medication for use by the child. Such plan shall include a statement that the child is capable of self-administering the medication under the treatment plan. The childs parent or guardian has completed and submitted to the school any written documentation required by the school, including the treatment plan required in (3) above and the liability statement required in (5) below. The childs parent or guardian has signed a statement acknowledging that the school district and its employees or agents shall incur no liability as a result of any injury arising from the self-administration of medication by the child or the administration of such medication by school staff. Such statement shall not be construed to release the school district and its employees or agents from liability for negligence. (Missouri Revised Statute: Chapter 176; Pupils and Special Services; Section 167.627;08-28-2006). Medication Name: __________________________ Dose: __________________ Time or Interval: _________________________________ Route/Inhalation Device: ______________________ Instructions: ______________________________________________________________ Medication Name: __________________________ Dose: __________________ Time or Interval: _________________________________ Route/Inhalation Device: ______________________ Instructions: ______________________________________________________________ Allergies (List known allergies to medications, foods or air-borne substances.) _____________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ I, the parent or legal guardian of the student listed above, give permission for this child to carry and self-administer the above-listed medications. I have instructed my child to notify the school staff anytime this device is used. I understand that, absent any negligence, the school shall incur no liability as a result of any injury arising from the self-administration of medication by my child. Signature of Parent or Legal Guardian: ___________________________________________ Date: __________________________ Parent/Guardian: Name: _________________________________________ Home Phone: _________________________________________________ Address: _______________________________________ Work and Cell Phones: _________________________________________ Name: _________________________________________ Home Phone: _________________________________________________ Address: _______________________________________ Work and Cell Phones: _________________________________________ Emergency Contact: Name: _________________________________________ Phone #s: ___________________________________________________  I, a licensed physician or nurse practitioner, certify that this child has a medical history of severe allergic reactions, has been trained in the use of the listed medication, and is judged to be capable of carrying and self-administering the listed medication(s). The child should notify school staff anytime the medication/injector is used. The child understands the hazards of sharing medications with others and has agreed to refrain from this practice. Signature of Healthcare Provider: ____________________________________________________________ Date: _____________________ Name of Healthcare Provider: _________________________________ Phone: _______________________ Fax: ________________________ Address: __________________________________________________ City: _________________________ Zip: ________________________  ( ( ( ( ( ( (  FILE: JHCF-AF4 Critical Note: The reader is encouraged to review policies and/or procedures for related information in this administrative area. Implemented: 02/23/2011 Revised: 04/15/2011 Windsor C-1 School District, Imperial, Missouri  FILE: EFEA BASIC DISTRIBUTION OF NON-COMMERCIAL FOODS (Shared Foods in the School Environment) In the interest of providing a safe and healthy environment, the Windsor C-1 School District prohibits the consumption of shared foods during the school day. Some medical conditions and allergic reactions to food ingredients pose a serious risk to student safety. This risk is higher when food ingredients are unknown or when appropriate food preparation conditions cannot be controlled. Therefore, only prepackaged foods with nutritional labeling may be brought to school for student consumption. Home-prepared foods are not permitted or sold to students during the school day. This policy does not pertain to students individual lunches and /or snacks brought from home for personal consumption. Student Allergy Prevention and Response Policy Parent Signature Page Please sign on the line below acknowledging that you have read and understand the Windsor C-1 School Districts Student Allergy Prevention and Response Policy. 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