INDIVIDUALIZED EPINEPHRINE EMERGENCY ACTION PLAN

Place
Child’s
Picture
Here

Student’s Name:______DOB:______GRADE:______

ALLERGY TO:______

ASTHMATIC Yes *_____ NO_____ *High risk for severe reaction

SIGNS OF AN ALLERGIC REACTION

(Highlight or circle symptoms appropriate to child)

Systems: Symptoms:

·  Mouth Itching and swelling of the lips, tongue, or mouth

·  Throat Itching and/or a sense of tightness in the throat, hoarseness, and hacking cough

·  Skin Hives, itchy rash and/or swelling about the face or extremities

·  Gut Nausea, vomiting, abdominal cramps and/or diarrhea

·  Lung * Shortness of breath, repetitive coughing and/or wheezing

·  Heart * Thready pulse, passing out

The severity of symptoms can quickly change. *All above symptoms can potentially progress

to a life threatening situation.

1. If an allergic reaction is suspected, give: _____0.3mg Epi-Pen IM or _____0.15mg Epi-pen Junior IM

and Benadryl ______PO immediately.

dosage

2. Call Emergency Medical Services: 9-1-1

3. Call School Nurse if not present.

4. Call: Mother______

(home) (work) (cell)

Call: Father______

(home) (work) (cell)

or emergency contacts (listed on other side)

5. Possible side effects of Epi-Pen: Palpitations, tachycardia (rapid heart beat), sweating, nausea,

vomiting, breathing difficulties, pale skin color, dizziness, weakness, tremor, headache, anxiety

apprehension, and nervousness.

6. Stay with child until emergency help arrives – position child on left side.

DO NOT HESITATE TO ADMINISTER MEDICATION OR CALL EMERGENCY MEDICAL SERVICES, EVEN IF PARENTS CANNOT BE REACHED!

Physician Signature:______Date:______

v  All students must be transported to the hospital by Emergency Medical Services (EMS) after receiving Epi-pen.

I give permission for the school nurse (or appropriately trained school personnel) to administer Epi-Pen and share information as deemed necessary for my child’s health and safety.

I give permission for my son/daughter to self-administer their Epi-Pen as prescribed by his/her physician. ______Yes ______No

Parent Signautre:______Date:______

Nurse Signature:______Date:______

Epi-Pen Location(s): Expiration Date(s):

______

______

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