Office of the Superintendent

Name: ______

EMERGENCYACTION PLAN

HEMOPHILIA

Hemophilia is a genetic disorder of blood clotting caused by a deficiency of one of the clotting proteins, factor VIII (hemophilia A) or IX (hemophilia B). People with hemophilia experience bleeding into joints, muscles, and soft tissues as well as prolonged bleeding as a result of trauma or surgery. Bleeding episodes are prevented or treated with an intravenous infusion of the missing clotting factor. People with mild hemophilia A are sometimes treated with DDAVP (Stimate nasal spray). Prompt, early treatment of bleeding

episodes is best for prevention of complications of bleeding.

SYMPTOMS: The student says he is having a bleed, or the student sustains an injury or trauma. Symptoms of a bleed may include tingling or bubbling feeling in joint, limb held in abnormal position, discomfort or pain, area warm to touch, swelling, firmness or tenderness at the site of bleeding, restriction of range of motion. (The student may only have one of these symptoms.)

  • Joints and muscles are most common bleeding sites.
  • Any injury to or bleeding around the head and neck area is a medical emergency unless it is a nosebleed
  • Trauma that occurs at school should be assessed. Parents should be notified so that they can implement a plan of care.

INTERVENTIONS:

  1. Note the location of pain or bleeding and notify parents or caregivers promptly.

2. Control external bleeding by applying pressure to the site for 10-15 minutes.

3. Elevate the site. Apply ice/cold pack.

4. Allow child to rest while waiting for parent.

5. Resume activity slowly after bleeding episode.

6. Do NOT give aspirin or medicine containing aspirin for pain relief.

7. If bleeding is uncontrolled, or in head or neck region (except nosebleeds),

contact parents regarding emergency care. Call 911 and transport to

______hospital as necessary.

8. Additional instructions: ______

______

Parent/Guardian Signature______Date______

Parent Phone Number(s) ______

Nurse Signature______Date______

Dates of verification/review (nurse signature)/CurrentSchool location:

______/______/______

______/______/______

______/______/______

This information will be shared with your child’s teacher unless you state otherwise

SCHOOL HEMOPHILIA RECORD

Name of Student______School______

Grade______Year______

Parent/Guradian______Phone______

______Phone______

Health Care Provider______Phone______

1. Does your child wear a “medic alert” bracelet? ____ Yes ____ No

2. What type of hemophilia does your child have? ______

______

  1. Is your child receiving medication (clotting factor) to prevent bleeding episodes on a regular schedule? ____ Yes ____ No

4. How often does he/she have bleeding episodes? ______

5. Does your child have a particular joint that bleeds frequently? ______

______

6. Describe symptoms when a bleeding episode occurs: ______

______

7. List activities in which your child should NOT fully participate: ______

______

8. Name medications taken routinely for pain relief or bleeding management: ______

______

  1. In the event of a bleed, what steps should school personnel take? ______

______

If medication is needed at school a Request for Medication Administration form must be completed and signed by parent and physician. Medication forms are available from the school office.

PLEASE READ THE EMERGENCY PLAN FOR HEMOPHILIA ON THE

REVERSE SIDE, AND ADD ANY FURTHER INSTRUCTIONS THAT YOU

WISH FOR YOUR CHILD.

June 2010