Microsoft word - new anaphylaxis allergy food ihp.doc

Montgomery County Schools Health Services ANAPHYLAXIS/SEVERE ALLERGY/FOOD ALLERGY—Individualized Health Care Plan (IHP) Educational Goal: Student will maintain health and well being necessary for learning. Staff will work with student and parent/guardian in the prevention of episodes and will stress the importance of compliance with avoiding the specific allergen or allergens as prescribed by health care provider. Student Name: ____________________________________ DOB: ___________ School Year: ____________________ History of Asthma: __ NO __ YES—higher risk for reaction Student rides bus # ___________________ Parent/Guardian: __________________________________Telephone #s: ____________________________________________ Other Emergency Contact: ___________________________ Telephone #s: ___________________________________________ Notify parent in the following situations: _______________________________________________________________________ Parent is responsible to notify nurse, teacher(s), front office and food service staff of all known allergies. ALLERGY: (check appropriate) To be completed by Health Care Provider ___ Foods (list): ________________________________________________________________________ ___ Medications (list): ___________________________________________________________________ ___ Latex: Circle: Type I (anaphylaxis) Type IV (contact dermatitis) ___ Stinging Insects (list): ________________________________________________________________ Action Plan- Parent/guardian is responsible for all medication & supplies. This form is adapted from The Food Allergy Anaphylaxis Network, “Food Allergy Action Plan” & the Asthma and Allergy Foundation of America, Chart to be completed by Health Care Provider If food ingested or contact with allergen occurs Itching, tingling, or swelling of lips, tongue, mouth Hives, itchy rash, swelling of the face or extremities Nausea, abdominal cramps, vomiting, diarrhea Throat+ Tightening of throat, hoarseness, hacking cough Shortness of breath, repetitive coughing, wheezing Thready pulse, low BP, fainting, pale, blueness Disrientation, dizziness, loss of consciousness If reaction is progressing (several of the above areas affected), GIVE: The severity of symptoms can quickly change. + Potentially life-threatening Never ask a student with symptoms of an allergic reaction to wait until the end of a lesson or class when they are in distress. If symptoms are severe, call the nurse to come to the student The following adaptations/modifications or precautions are required during school hours: __ Dietary modifications to school meals—Parent must provide dietary personnel with a physician’s order for dietary modification __ Designate a “No-Peanut” zone in the cafeteria __ Classroom teacher (s) will assist student to avoid exposure to allergens as much as possible on a daily basis, at parties and on field trips. __ School Personnel will assist student to avoid exposure to food allergens by making parent aware of all parties, food sales, and field trips at least one week in advance. Other nursing intervention specific to this student: : __________________________________________________________________ Montgomery County Schools Health Services Student will come to the health unit for supervised administration of the following medication(s) unless otherwise ordered in written physician’s orders, in accordance with Montgomery County Schools Medication Administration Policy and Procedures: ___Antihistamine: Liquid Diphenhydramine (Benadryl®) dosage: _____________ only if able to swallow ___ Other Antihistamine ________________________________ dosage: _____________ only if able to swallow If symptoms do not improve in __________ minutes: ___ Repeat medication(s) as ordered by the health care provider. ___ Contact parent/guardian from further instructions ___ Administer Epinephrine only if ordered by physician and provided by the parent ____ In an emergency Student is to receive Epinephrine: Inject into outer thigh ___ 0.3 mg OR ___ 0.15 mg. Student is to have emergency medication available to them at all times, but SHOULD NOT carry the auto-injector. ___ Parents are to maintain a supply of medication at school & will be notified when the supplies or medication needs replacement. Signature of Healthcare Provider: __________________________________________________________ Date: _______________ All changes in medication/treatments must be sent to school in writing signed and dated by the physician SELF-ADMINISTRATION—MUST BE SIGNED MY HEALTHCARE PROVIDER This section must be completed by Student’s Physician before the student will be permitted to self-administer medication. Pursuant to KRS 158.832 to KRS 158.836 a student may possess and self-administer medication at school and at school-related functions upon completion of the following information by the parent/ guardian and the student’s physician and waiver of liability by the parent/guardian. Please indicate if you have provided additional information: ___ This student, _____________________, has received instruction in the proper use of the Auto-injector: EpiPen® or Twinject® (circle one) and may self-administer: ___ independently __ Student is to have emergency medication______________________________________________________ with them at all times. It is my professional opinion that this student SHOULD be allowed to carry and use the auto-injector independently. He/she knows when to request antihistamine and has been advised to inform a responsible adult if the auto-injector is self-administered. __ Back-up medication is to be stored at school—must be provided by the parent/guardian Signature: ________________________________________________________________________________________ Date: ___________________________ Physician or Authorized Healthcare Provider All changes in medication/treatments must be sent to school in writing signed and dated by the physician. *I give permission for the information on this form to be shared with teachers, principals, and other school personnel that have direct contact with my child for the current school year. I give consent for the staff of the Montgomery County Schools to assist my child to comply with his/her physician’s prescribed medications or treatments. I hereby agree to release and hold the staff free and harmless for any claims, demands, or suits for damages from any injury or complication that may result from such treatment described by me contained on this consent form unless it results from the gross negligence of Montgomery County School staff. A nurse from Montgomery County will contact the student’s Parent/Guardian to discuss any concerns regarding the student’s care which might require medical follow-up and/or will contact the health care provider to obtain current information verbally when necessary to manage the student’s condition at school. Date of contact & changes ordered by licensed provider notes on attached nurse’s note. Health Care Provider: _______________________________________________ Telephone #: ________________________________. *____________________________________________ ________ ______________________________________ Student’s Parent/Guardian Date Received by & Date received

Source: http://www.montgomery.k12.ky.us/docs/New%20Anaphylaxis%20Allergy%20Food%20IHP.pdf