Microsoft word - 09 anaphyax mgmt plan.doc

ANAPHYLAXIS MANAGEMENT & ACTION PLAN Patient’s Name _____________________________________________________ DOB _____________________________ Date Completed __________________ Parents’ Name _____________________________________________________ Permission to carry meds? _______yes __ _ no ___ My child has food, contact, medication or insect bite allergies that could require use of epinephrine This device is located _________________________________________________________________________ Child knows how to self-use: ___ yes ___no Food allergens: Contact Allergens:
Insect Bite Allergens
Medications
_______________________________ ____________________________ ________________________ _________________ _______________________________ ____________________________ ________________________ _________________ _______________________________ ____________________________ ________________________ _________________ _______________________________ ____________________________ ________________________ _________________ _______________________________ ____________________________ ________________________ _________________ Physician’s Name ____________________________________________ Phone _________________________ Name __________________________ Preferred Hospital ____________________________________________ Address ________________________ Phone _________________________ Preferred Ambulance Service ___________________________________ Phone _________________________ Relationship ____________________ Health Insurance _____________________________________________ Policy # ________________________ Parental Contact: Home Address __________________________________________________ City _____________________________ Zip _____________________ Home Phone ______________________________ Father’s cel __________________________ Father’s work phone _________________________ Mother’s cel _______________________________ Mother’s work phone ____________________________________ Nearest relative: Name ____________________________________________ Relation _____________________________ Phone ___________________ Mouth: itching & swel ing of lips, tongue or the mouth Throat: itching &/or tightening in throat, hoarseness, cough Skin: itchy rash, hives, swel ing in face or extremities Gut: nausea, cramps, vomiting, &/or diarrhea Lung: shortness of breath, repetitive coughing &/or wheezing Heart: “thready” pulse, fainting Al or any of these symptoms can progress to life-threatening anaphylactic reaction. Monitor closely. If child also has asthma, a sudden onset of asthma symptoms may indicate al ergic reaction if there was any indication of contact with their al ergic al ergens. If any of above symptoms appear upon contact or suspected contact with al ergen, epinephrine must be administered immediately. Note: injecting epinephrine if not needed wil not be harmful. Fol ow these procedures: 2) Physician directs that teacher or nurse gives epinephrine for any symptom beyond one or two hives: ____yes ___no Physician directs instead________________________________________________________________________________________________________________ A child may know how to use a device but in emergency may not be able to do so. Adult uses the auto-injector, injecting through clothing if required, into the thigh at finger tip level. Try to avoid the seam on jeans. Ask child to lie stil , adult remain with child at al times. 3) Physician directs, after injection, adult gives Benedryl or other antihistamine: ___yes ___no Instead, ________________________________ ______________________________________. If child has asthma, physician directs to give 2 puffs of albuterol: ___yes ___no. 4) After 5 minutes, nurse or teacher reassess reaction. If not improving, inject second dose of epinephrine. 5) Immediately when reaction occurs, another adult calls 911, fol owing emergency procedure plans. Cal parents and tel them what hospital child wil go to. Nurse or teacher remains with student at al times, accompanying them to hospital till parent arrives. Provide copy of emergency plan and contact info to medics. Take al their medications with you to hospital. Special Instructions: ___________________________________________________________________________________________________ Physician’s Signature ________________________________________________________ Date _________________ Parent/Guardian Signature ____________________________________________________ Date _________________

Source: http://www.ccisd.net/docs/health-services-docs/anaphylaxis-management-action-plan-form.pdf?sfvrsn=0