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Microsoft word - 6-210 schodack severe allergy policy 61710.doc

Anaphylaxis/Severe Allergy Policy
Background (Allergy and Anaphylaxis Overview) The incidence of severe allergic reactions has been rising at an alarming rate, especially with regard to food. Other common causes of anaphylaxis include allergies to latex, medications, and insect stings. Pathophysiology and Treatment Anaphylaxis can affect almost any part of the body and cause various symptoms. The most dangerous symptoms include breathing difficulties and a drop in blood pressure or shock, which are potentially fatal. Medications to control or treat severe allergies and anaphylaxis include: Treatment of anaphylaxis is centered on treating the rapidly progressing effects of the histamine release in the body with epinephrine. The allergen should also be removed immediately. Creating an Allergen-Safe School Environment (Importance of Prevention) Protecting a student from exposure to offending allergens is the most important way to prevent life-threatening anaphylaxis. The risk of exposure to allergens for a student is reduced when the school personnel, medical provider and parent/guardian work together to develop a management plan for the student. Educating the entire school community about life-threatening allergies is important in keeping students with life-threatening allergies safe. Identifying the School Team The Schodack Central School District’s Health Office Staff should be responsible for developing and overseeing the implementation of the district’s severe allergy policy. Action Steps for Anaphylaxis Management 1. The district will provide severe allergy awareness training for all school employees. The session will be approximately 15 minutes and held periodically at the discretion of the district health office staff and district administration. 2. School health office personnel will provide training to adults who have specific responsibility and interaction with students who may need severe allergy medications administered. Records of such training will be maintained in individual student health files. 3. School health office personnel shall maintain individualized healthcare plans and emergency care plans for students as necessary. Copies of such plans will be kept in the nurse’s office. 4. The school health office will provide information on the severe allergies of specific students to teachers, the transportation coordinator, librarians, and other school staff members who regularly supervise the student. 5. Additionally, the district shall implement the following steps to assist in protecting individuals with severe allergies, including: a. Having standing emergency medical protocols for nursing staff. b. Maintaining stock supplies of life saving emergency medications, as allowed by the laws of NYS, such as EpiPens, in all health offices for use in first time emergencies. c. Following specific legal documents duly executed in accordance with the laws of NYS with medical orders regarding the care of specific students with severe life-threatening conditions. d. Allowing self-directed students as assessed by the school nurse to carry life saving medication with prior approval by the medical provider, and according to health practice and procedures, as long as duplicate life saving medication is also maintained in the health office in the event the self-carrying student e. Assuring appropriate and reasonable building accommodations are in place within a reasonable degree of medical certainty Resources (if deemed appropriate information from:) ƒ Health History ƒ Care Plan (IHP or ECP) ƒ Online training course ƒ Available at www.schoolhealthservicesny.com Approved: 8/19/10 (3rd 8/19/10, 2nd 7/1/10, 1st 6/17/10) Schodack Central School District 
DETERMINATION OF SELF‐DIRECTED STUDENTS 
Reason for Medication:
_______________

THIS STUDENT:

Recognizes his/her medication
Knows how much medication he/she takes
Knows what time his/her medication is needed during the school day
Knows why he/she takes this medication
Knows what happens when he/she doesn’t take their medication
Knows when to refuse to take his/her medicine when appropriate

‰ This student meets the criteria to be determined to be self-directed.
‰ This student does not meet the criteria to be determined to be self-directed.
Plan to assist student in becoming self-directed: Signature:
______________
Schodack Central School District 
AUTHORIZATION TO ADMINISTER INTERNAL MEDICATION BY A STUDENT


PLEASE COMPLETE BOTH PARTS
A.
I, ________________________ request that _____________________________ be allowed to carry on (Name of parent or guardian) (Name of student)
his/her person the medication prescribe by ________________________________________.
I request that faculty & staff working with my This is to certify that ___________________________ is being attended and treated by me. It is essential that he/she be in possession of the following medication in the dose indicated during school hours, on field trips or for sports events. I have instructed this student in the administration, dosage, possible side effects and safety rules regarding medication. Name of medication (or other identification) ___________________________________________________________ Dosage Schedule ____________________________________________________________________________ Possible Side Effects/Adverse Reactions _________________________________________________________ Length of time to be given (Please check one) ____ Indefinitely ____To be discontinued on __________ (Date)
Note: It is the parent’s responsibility to see that the School Nurse-Teacher receives this authorization.

Medication to be supplied by parent, not from health office supply.
Schodack Central School District 
AUTHORIZATION TO ADMINISTER INTERNAL MEDICATION BY SCHOOL PERSONNEL
I, _______________________________ request that the school Nurse-Teacher (or authorized personnel) (Name of parent or guardian) administer to ___________________________________ the medication prescribed by (Name of student) __________________________________. I request that faculty & staff working with my This is to certify that ____________________________________ is being attended and treated by me. It is essential that he/she be given the following medication in the does indicated during school hours for treatment of ____________________________________________________________________________________________. Name of medication (or other identification) ________________________________________________________________________ Dosage Schedule_______________________________________________________________________________ Possible Side Effects/Adverse Reactions____________________________________________________________ Length of time to be given (Please check one)______Indefinitely ______To be discontinued on __________(Date) ________________________________
Note: It is the parent’s responsibility to see that the School Nurse-Teacher receives this authorization.

Medication to be supplied by parent, not from health office supply.
Schodack Central School District 
ANAPHYLAXIS PROTOCOL
Non-Licensed School Staff Members

An unlicensed staff member may be trained to administer an Epi-Pen in anticipation of an Anaphylactic reaction, under the following
circumstances:

¾ The individual agrees to render emergency care to the student, who may have a Life Threatening Hypersensitivity reaction to a
previously encountered allergen (ANAPHYLAXIS). (Such a response would fall under the “Good Samaritan Act” for rendering
emergency care during a life-threatening situation.)

¾ The individual has been given approval by a Registered Nurse/Nurse Practitioner to assist the student in the event of an
Anaphylactic reaction.
¾ The individual receives proper in-service training for the procedure from a Registered Nurse/Nurse Practitioner.
¾ The training is documented by the health care professional who conducts the training.
¾ Ongoing assessment and supervision is conducted by the health care professional.
STUDENT’S EMERGENCY CARE PLAN
EPI-PEN MUST ACCOMPANY HIM/HER ON ALL FIELD TRIPS

Name of Student:
______________________________________________________________ Allergy:___________________________________
The following staff member successfully demonstrated proficiency in the use of the Epi-Pen Auto Injector Training Device
Staff Member Trained:
___________________________________________Position:_____________________________Date:________________


Trainer: (Must be Registered Nurse)____________________________________________________________________ Date:________________

Schodack Central School District 
ANAPHYLAXIS PROTOCOL
Explanation/Demonstration by Registered
Explanation /Return
Demonstration by unlicensed Staff Member
Date: RN initials:
Date: Staff member’s initials:
A. States Name and Purpose of Emergency Medication:
• The Epi-Pen Auto-Injector is a disposable, pre-filled automatic injection device that is designed to deliver a single dose of 0.3 mg (or 0.1 mg for children) of epinephrine to an individual with a known Anaphylactic condition. B. Signs and Symptoms of Anaphylaxis:
• Itching and swelling of lips, tongue and mouth. • Tightness in throat, hoarseness, hacking cough. • HIVES, itchy rash, swelling about the face or extremities. • Nausea, stomach cramps, vomiting and/or diarrhea. • Shortness of breath, wheezing, repetitive coughing. • Passing out.
C. EMERGENCY TREATMENT:
(For Training Purposes, use Epi-Pen Trainer) • Have someone call 911 immediately
Administer emergency medication (Epi-Pen)
Pull off gray safety cap.
Place black tip on thigh, at right angle to leg.
Press hard into thigh (through clothing) until Auto-Injector
mechanism functions.
Hold in place for 10 seconds!!
Remove Epi-Pen unit and discard.
Massage injection area.
Call parent or parent designee
Call student’s physician to inform of emergency
Record administration of Epi-Pen on the Emergency Medical Care
Plan Anecdotal Record (Send with student to hospital)
Student will be transported to hospital via ambulance.
Schodack Central School District 
BEE STING ALLERGY
Asthmatic: ‰ Yes ‰ No (increased risk for severe reaction) Severity of reaction(s):
SYMPTOMS OF AN ALLLERGIC REACTION MAY INCLUDE ANY/ALL OF THESE:
Itching & swelling of lips, tongue or mouth ƒ THROAT
Itching, tightness in throat, hoarseness, cough Hives, itchy rash, swelling of face and extremities ƒ STOMACH
Nausea, abdominal cramps, vomiting, diarrhea Shortness of breath, repetitive cough, wheezing “Thready pulse”, “passing out”
The severity of symptoms can change quickly –

it is important that treatment is given immediately.
STAFF MEMBERS INSTRUCTED:

TREATMENT:

Remove stinger if visible, apply ice to area. Treatment should be initiated ‰ with symptoms ‰ without waiting for symptoms Benadryl ordered: Call school nurse. Call parent/guardian if off school grounds. Epinephrine ordered: IF ANY SYMPTOMS BEYOND REDNESS OR SWELLING AT THE SITE OF THE STING ARE PRESENT AND
EPINEPHRINE IS ORDERED, GIVE EPINEPHRINE IMMEDIATELY AND CALL 911.
Epinephrine provides a 20-minute response window. After epinephrine, a student may feel dizzy or have an increased heart
rate. This is a normal response. Students receiving epinephrine should be transported to the hospital by ambulance. A staff
member should accompany the student to the emergency room if the parent, guardian or emergency contact is not present and
adequate supervision for other students is present.
Transportation Plan: ‰ Medication available on bus ‰ Medication NOT available on bus ‰ Does not ride bus
Parent/Guardian Signature to share this plan with Provider and School Staff:
Schodack Central School District 
Schodack Central School District 
FOOD ALLERGY
Asthmatic: ‰ Yes ‰ No (increased risk for severe reaction) Allergen(s):
SYMPTOMS OF AN ALLLERGIC REACTION MAY INCLUDE ANY/ALL OF THESE:

Itching & swelling of lips, tongue or mouth, mouth “feels hot” ƒ THROAT
Itching, tightness in throat, hoarseness, cough Hives, itchy rash, swelling of face and extremities Nausea, abdominal cramps, vomiting, diarrhea Shortness of breath, repetitive cough, wheezing The severity of symptoms can change quickly –
it is important that treatment is given immediately.
STAFF MEMBERS INSTRUCTED:
TREATMENT:
Rinse contact area with water if appropriate Treatment should be initiated ‰ with symptoms ‰ without waiting for symptoms Benadryl ordered: ‰ Yes ‰ No Call school nurse. Call parent/guardian if off school grounds. Epinephrine ordered: ‰ Yes ‰ No Special instructions: IF INGESTION OR SUSPECTED INGESTION OF ALLERGEN OCCURS, SYMPTOMS ARE PRESENT AND
EPINEPHRINE IS ORDERED, GIVE EPINEPHRINE IMMEDIATELY AND CALL 911.
Epinephrine provides a 20-minute response window. After epinephrine, a student may feel dizzy or have an increased heart
rate. This is a normal response. Students receiving epinephrine should be transported to the hospital by ambulance. A staff
member should accompany the student to the emergency room if the parent, guardian or emergency contact is not present and
adequate supervision for other students is present.
Transportation Plan: ‰ Medication available on bus ‰ Medication NOT available on bus ‰ Does not ride bus
Parent/Guardian Signature to share this plan with Provider and School Staff:
Schodack Central School District
LATEX ALLERGY


SYMPTOMS OF AN ALLLERGIC REACTION MAY INCLUDE ANY/ALL OF THESE:

Itching & swelling of lips, tongue or mouth ƒ THROAT
Itching, tightness in throat, tightness in chest Hives, warmth, itchy rash, generalized swelling Nausea, abdominal cramps, vomiting and/or diarrhea Shortness of breath, repetitive cough, wheezing The severity of symptoms can change quickly –
it is important that treatment is given immediately.
STAFF MEMBERS INSTRUCTED:

TREATMENT:
Rinse contact area with water.
Benadryl ordered:
. Call parent/guardian if off school grounds. IF ANY SYMPTOMS BEYOND REDNESS OR SWELLING ARE SEEN AT THE SITE AND EPINEPHRINE IS
ORDERED, GIVE EPINEPHRINE IMMEDIATELY AND CALL 911.
Epinephrine provides a 20-minute response window. After epinephrine, a student may feel dizzy or have an increased heart
rate. This is a normal response. Students receiving epinephrine should be transported to the hospital by ambulance. A staff
member should accompany the student to the emergency room if the parent, guardian or emergency contact is not present and
adequate supervision for other students is present.
Transportation Plan: ‰ Medication available on bus ‰ Medication NOT available on bus ‰ Does not ride bus
Parent/Guardian Signature to share this plan with Provider and School Staff:
Schodack Central School District 
SEIZURE DISORDER

Student:

SYMPTOMS OF A SEIZURE EPISODE MAY INCLUDE ANY/ALL OF THESE:

o Entire body stiffens, jerking movements o May cry out, turn bluish, be tired afterwards
STAFF MEMBERS INSTRUCTED:

TREATMENT:

Clear the area around the student to avoid injury. DO NOT PUT ANYTHING IN THE STUDENT’S MOUTH. Place student on side if possible, speak to student in reassuring tone. ‰ Emergency Medical Services (911) should be called, student transported to hospital. Preferred ‰ Emergency medication to be given by Nurse at onset of seizure.
‰ Student should be allowed to rest following seizure, call parent. Transportation Plan: ‰ Medication available on bus ‰ Medication NOT available on bus ‰ Does not ride bus
‰ Copy provided to Parent ‰ Copy sent to Healthcare Provider Parent/Guardian Signature to share this plan with Provider
Schodack Central School District 
DIABETES HYPERGLYCEMIA

Student:

SYMPTOMS OF A HYPERGLYCEMIC EPISODE MAY INCLUDE ANY/ALL OF THESE:

ƒ Gradual Onset
ƒ Extreme thirst, very frequent urination, drowsiness
ƒ Flushed skin, heavy breathing, blurred vision
ƒ Vomiting, fruity or wine-like odor to breath

SEVERE SYMPTOMS INCLUDE:

STAFF MEMBERS INSTRUCTED:

TREATMENT:

Call 911 to access Emergency Medical Services – transport to hospital by ambulance.
Notify parents/guardian (do not delay treatment by calling – obtain treatment for student first). ‰ Copy provided to Parent ‰ Copy sent to Healthcare Provider Parent/Guardian Signature to share this plan with Provider
Schodack Central School District 
DIABETES HYPOGLYCEMIA

SYMPTOMS OF A HYPOGLYCEMIC EPISODE MAY INCLUDE ANY/ALL OF THESE:

ƒ Shaking, fast heartbeat, sweating, anxiety, irritability
ƒ Complaints of hunger, imparied vision, weakness or fatigue
ƒ Onset may be sudden and can progress to insulin shock
SEVERE SYMPTOMS INCLUDE:
ƒ Appears very pale, feels faint, loss of consciousness ƒ Seizure activity

STAFF MEMBERS INSTRUCTED:


TREATMENT:

Accompany the student to the Health Office. Notify school nurse immediately. If off school grounds, provide a source of glucose: Notify parents/guardian (do not delay treatment by calling – obtain treatment for student first). STEPS TO FOLLOW FOR A HYPOGLYCEMIC EMERGENCY
Glucagon ordered ‰ Yes ‰ No
If Glucagon is ordered it should be given by a willing volunteer who has been trained by the school nurse, if student is
unconscious, unresponsive or having a seizure.
After Glucagon is given, call 911. Notify parents. Preferred hospital if transported: ___________________________
Students receiving glucagon without their parents or guardian present should be transported to the hospital by ambulance. A
staff member should accompany the student to the emergency room if the parent, guardian or emergency contact is not present
and adequate supervision for other students is present.
‰ Copy provided to Parent ‰ Copy sent to Healthcare Provider Parent/Guardian Signature to share this plan with Provider
Schodack Central School District 

SYMPTOMS OF AN ASTHMA EPISODE MAY INCLUDE ANY/ALL OF THESE:
ƒ CHANGES IN BREATHING: coughing, wheezing, breathing through mouth,
ƒ VERBAL REPORTS of: chest tightness, chest pain, cannot catch breath,
dry mouth, “neck feels funny”, doesn’t feel well, speaks quietly. ƒ APPEARS: anxious, sweating, nauseous, fatigued, stands with shoulders hunched
SIGNS OF AN ASTHMA EMERGENCY:
ƒ Breathing with chest and/or neck pulled in, sits hunched over, nose opens wide when inhaling. Difficulty in walking and talking. ƒ Blue-gray discoloration of lips and/or fingernails. ƒ Failure of medication to reduce worsening symptoms with no improvement 15 – 20 minutes after initial treatment. ƒ Peak Flow of ƒ Respirations greater than 30/minute. ƒ Pulse greater than 120/minute.
STAFF MEMBERS INSTRUCTED:

TREATMENT:

Stop activity immediately. Help student assume a comfortable position. Sitting up is usually more comfortable. Encourage purse-lipped breathing. Encourage fluids to decrease thickness of lung secretions. Give Observe for relief of symptoms. If no relief noted in 15 – 20 minutes, follow steps below for an asthma emergency. Notify school nurse at who will call parents/guardian and healthcare provider. STEPS TO FOLLOW FOR AN ASTHMA EMERGENCY:
• Call 911 (Emergency Medical Services) and inform them that you have an asthma emergency. They will ask the student’s age, physical symptoms, and what medications he/she has taken and usually takes. • A staff member should accompany the student to the emergency room if the parent, guardian or emergency contact is not present and adequate supervision for other students is present. Preferred Hospital if transported: Parent/Guardian Signature to share this plan with Provider and School Staff:
SCHODACK CENTRAL SCHOOL DISTRICT
PERMISSION FORM FOR PRESCRIBED MEDICATION
Child’s Name:_________________________________________________________ D.O.B_______________________ TO BE COMPLETED BY THE PHYSICIAN OR AUTHORIZED PRESCRIBER Name of Medication:__________________________________________________________________________ Reason for Medication:_________________________________________________________________________ Form of Medication/Treatment: _______Tablets/capsule _______Liquid _______Inhaler _______Injection _______Nebulizer _______Other Instructions (schedule and dose to be given at school):________________________________________________ ____________________________________________________________________________________________ Start________date form received Other date____________ __________ for emergency events only Stop________end of school year Other date/duration____________ Possible side effects and adverse reactions (if any):___________________________________________________ ____________________________________________________________________________________________ The student is both capable and responsible for self-administering this medication: ________No _________Yes, supervised __________Yes, unsupervised The student may carry this medication: ________No _________Yes, supervised __________Yes, unsupervised Physician’s Signature___________________________________________ Date___________________________ CONTROLLED SUBSTANCE. PILLS MUST BE SECURELY STORED AND To be completed by parent/guardian: I give permission for (Name of Child) ___________________________________________________ to receive the above medication at school according to standard school policy. Parent/Guardian Signature:_______________________________________________________Date:_____________________ SCHODACK CENTRAL SCHOOL DISTRICT
PARENT/GUARDIAN AUTHORIZATION FOR MEDICATION ADMINISTRATION
Student Name:_______________________________________________________D.O.B.:_________________________ Parent/Guardian Name:_________________________________________________________________________ Telephone Numbers:________________home ________________emergency Other person(s) to be notified in case of medication emergency: Name:_______________________________________ Telephone number:_______________________________ My son/daughter is currently receiving the following medication(s):_____________________________________ ____________________________________________________________________________________________ My son/daughter has FOOD or DRUG ALLERGIES: _____No
(if Yes) list:_______________________________________________________________________________
I understand that the School Nurse, or other designated person in case of the absence of the School Nurse, will
administer the medication, including field trips, prescribed by:
_________________________________________ to _________________________________________
Licensed

I understand the medication must be brought to school in the original container with specific orders and name of
medication.
I understand that medication and refills must be brought to school by parent, guardian, or responsible adult.
I understand that I may retrieve the medication from the school at any time; however, the medication will be
destroyed if it is not picked up within one (1) week following termination of the order or one (1) week beyond
the close of school.

I give permission for my son/daughter to self-administer medication, if the School Nurse determines it is safe and
appropriate.
I give permission to the School Nurse to share information relevant to the prescribed medication administration as he/she determines appropriate for my son/daughter’s health and safety. Parent/ Guardian Signature:_____________________________________________________ Date:_________________________ SCHODACK CENTRAL SCHOOL DISTRICT
EMERGENCY MEDICAL CARE PLAN
ANECDOTAL RECORD

Name of Student:
Date & Time of Event:
What Happened:
Actions Taken by Classroom Staff (per protocol):
______Student(s) Response to Emergency Measures:
************************************************************************************************************************
Principal Notified:__________

Time:__________
School Nurse Notified:__________
Time:__________

Physician Notified:__________

Time:__________
Notified:__________
Time:__________

Source: http://www.schodack.k12.ny.us/scs/boe/boepolicy/6-210_Schodack_Severe_Allergy_Policy.pdf

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