ࡱ> ] >bjbjzpzp 8 b b$  ,,|||8\$@Q@L $i( u*OOOOOOO$RUvP|?.1$^$?.?.P,, P U1U1U1?.,8 | OU1?.OU1U15Kd=M p^8.0KOQ<@QL8W!0W0=MW|=M}+,rU1,\,T}+}+}+PP0^}+}+}+@Q?.?.?.?.W}+}+}+}+}+}+}+}+}+ B :  Date Plan Developed/Revised: FORMTEXT       RIVERSIDE SCHOOL DISTRICT School Nurse # FORMTEXT       LIFE THREATENING ALLERGY LICENSED HEALTH PROFESSIONAL (LHP) ORDERS / CARE PLAN (Must be completed legibly by a licensed health professional) NAME  FORMTEXT      Severe ALLERGY to  FORMTEXT      Other Allergies:  FORMTEXT      School  FORMTEXT       Birth date  FORMTEXT      Grade  FORMTEXT      Routine medications (at home/school)Bus #  FORMTEXT       Car  FORMCHECKBOX  Walk  FORMCHECKBOX Date of last reaction:Please list the specific symptoms the student has experienced in the past:  FORMTEXT      Location(s) where Epi-pen/Rescue medications is/are stored:  FORMCHECKBOX  Office  FORMCHECKBOX  Backpack  FORMCHECKBOX  On Person  FORMCHECKBOX  Coach  FORMCHECKBOX  Other____________EMERGENCY CARE PLAN / LHP ORDERS If you suspect a severe allergic reaction to food, immediately determine the symptoms and treat the reaction as follows: Symptoms (known symptoms X)  FORMCHECKBOX  MOUTH Itching, tingling, or swelling of the lips, tongue, or mouth  FORMCHECKBOX  SKIN Hives, itchy rash, and/or swelling about the face or extremities  FORMCHECKBOX  THROAT Sense of tightness in the throat, hoarseness and hacking cough  FORMCHECKBOX  GUT Nausea, stomach ache/abdominal cramps, vomiting and/or diarrhea  FORMCHECKBOX  LUNG Shortness of breath, repetitive coughing, and/or wheezing  FORMCHECKBOX  HEART Thready pulse, passing out, fainting, blueness, pale  FORMCHECKBOX  GENERAL Panic, sudden fatigue, chills, fear of impeding doom  FORMCHECKBOX  OTHER  FORMTEXT      ______________________________________________ ( Asthma?  FORMCHECKBOX  Yes (High risk for severe reaction.)  FORMCHECKBOX  No ( If only lung symptoms are present without suspected ingestion first give:  FORMCHECKBOX  Fast acting inhaler ____________________________________________________  FORMCHECKBOX  Antihistamine  FORMCHECKBOX  Epi-pen ( If only inhaler is given and lung symptoms are not relieved within  FORMTEXT       minutes  FORMCHECKBOX  Repeat inhaler  FORMCHECKBOX  Antihistamine  FORMCHECKBOX  Epi-pen Medication Doses Epipen (0.3)  FORMTEXT       Epipen Jr. (0.15)  FORMTEXT      Side Effects:  FORMTEXT      Repeat dose of Epipen:  FORMCHECKBOX  Yes  FORMCHECKBOX  No If YES, when  FORMTEXT      Antihistamine  FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT      cc/mgGive:  FORMTEXT       Teaspoons  FORMTEXT       Tablets by mouth Side Effects:  FORMTEXT       GIVE MEDICATION AS ORDERED ABOVE & AN ADULT IS TO STAY WITH STUDENT AT ALL TIMES. ( NOTE TIME_________AM/PM (Epi-pen/adrenaline given) ( NOTE TIME__________AM/PM (Antihistamine given) CALL 911 IMMEDIATELY. 911 must be called WHENEVER Epi-pen is administered. DO NOT HESITATE to administer Epi-pen and to call 911 even if the parents cannot be reached. Advise 911 that the student is having a severe allergic reaction and Epi-pen is being administered. An adult trained in CPR is to stay with student monitor and begin CPR as necessary. Call the School Nurse or Health Services Main Office at FORMTEXT      . ( Student should remain with a staff member trained in CPR at the location where symptoms began until EMS arrives. ( Notify the administrator and parent/guardian ( Dispose of used Epi-Pen in  sharps container or give to EMS along with a copy of the Emergency Care Plan ( It is medically necessary for this student to carry an Epi-pen during school hours.  FORMCHECKBOX  Yes  FORMCHECKBOX  No ( Student may administer Epi-pen.  FORMCHECKBOX  Yes  FORMCHECKBOX  No ( Student has demonstrated use to LHP.  FORMCHECKBOX  Yes  FORMCHECKBOX  NoStart Date:  FORMTEXT      End Date:  FORMTEXT      Licensed Health Professional s SignatureToday s Date:  FORMTEXT  Phone:  FORMTEXT  Licensed Health Professional s Printed NameFax Number:  FORMTEXT  Licensed Health Professional (LHP) Orders / Care Plan for Severe Allergy Part 2 Individual Considerations Bus Transportation should be alerted to students allergy. ( This student carries Epi-pen on the bus  FORMCHECKBOX  Yes  FORMCHECKBOX  No ( Epi-pen can be found in  FORMCHECKBOX  Backpack  FORMCHECKBOX  Waistpack  FORMCHECKBOX  On Person  FORMCHECKBOX  Other (specify)  FORMTEXT       ( Student will sit at front of the bus  FORMCHECKBOX  Yes  FORMCHECKBOX  No Other (specify)  FORMTEXT      _____________________________________________________________________ Field Trip Procedures  Epi-pen should accompany student during any off campus activities. ( The student should remain with the teacher or parent/guardian during the entire field trip  FORMCHECKBOX  Yes  FORMCHECKBOX  No ( Staff members on trip must be trained regarding Epi-pen use and this health care plan (plan must be taken). 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FORMCHECKBOX  Middle school or high school student will be making his/her own decision.  FORMCHECKBOX  Alternative snacks will be provided by parent/guardian to be kept in the classroom.  FORMCHECKBOX  Parent/guardian should be advised of any planned parties as early as possible.  FORMCHECKBOX  Classroom projects should be reviewed by the teaching staff to avoid specified allergens. ( Student should have someone accompany him/her in the hallways.  FORMCHECKBOX  Yes  FORMCHECKBOX  No ( Other (specify)  FORMTEXT      ______________________________________________________________________ CAFETERIA  FORMCHECKBOX  NO Restrictions  FORMCHECKBOX  Student will sit at a specified allergy table.  FORMCHECKBOX  Student will sit at the classroom table cleansed according to procedure guidelines prior to student s arrival and following student s departure.  FORMCHECKBOX  Student will sit at the classroom table at a specified location. ( Cafeteria manager and hostess should be alerted to the student s allergy. ( Other  FORMTEXT      _____________________________________________________________________________ EMERGENCY CONTACTS Name  FORMTEXT      Home Phone  FORMTEXT      Work Phone  FORMTEXT      Other  FORMTEXT      2 Name  FORMTEXT      Home Phone  FORMTEXT      Work Phone  FORMTEXT      Other  FORMTEXT       ADDITIONAL EMERGENCY CONTACTS 1.  FORMTEXT      Relationship:  FORMTEXT      Phone:  FORMTEXT      2.  FORMTEXT      Relationship:  FORMTEXT      Phone:  FORMTEXT      I request this medication to be given as ordered by the licensed health professional (i.e.: doctor) I give Health Services Staff permission to communicate with the medical office about this medication. I understand that the medication/s will not necessarily be given by a school nurse (but also by trained and supervised school staff). I release school staff from any liability in the administration of this medication at school. Medical/Medication information may be shared with school staff working with my child and 911 staff, if they are called. All medication supplied must come in its originally provided container with instructions as noted above by the licensed health professional. I request and authorize my child to carry and/or self-administer their medication. Yes No This permission to possess and self-administer an Epi-Pen may be revoked by the principal/school nurse if it is determined that your child is not safely and effectively self-able to administer.  FORMTEXT       FORMTEXT      Parent/Guardian Signature DateFor District Nurse s Use Only: Student has demonstrated to the nurse, the skill necessary to use the medication and any device necessary to self-administer the medication. Device(s) if any, used_______________________________________ Expiration date(s): ____________________________________________  FORMTEXT       FORMTEXT      School Nurse Signature DateA copy of the Health Care Plan will be kept in the substitute folder and given to all staff members who are involved with the student.     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