SCHOOL SEIZURE RECORD

And

Emergency Action Plan

Please Complete both sides of the emergency medical plan for Seizures and add any further instructions you wish for your child.

Return to School Nurse as soon as possible.

NAME OF STUDENT ______

1. What type of seizures does your child have and how often do they occur?

2. Describe your child’s symptoms during and after the seizure episode.

3. Does your child have an aura or warning of seizure coming?

Is he/she able to notify anyone that a seizure is coming?

4. Name medications taken routinely:

How often and how much?

At home ______

At school ______

5.  Does your child suffer any side effects to these medications? ______

If so, please list ______

6.  Are there any sports/activities in which your child CANNOT fully participate?

7.  What steps do you want school personnel to take if a seizure should happen?

PLEASE NOTE: If medication is to be taken at school, a medication authorization form must be completed by parent and physician and be kept at school. These are obtained from your school nurse. This form is completed EVERY year.

OVER 04/2011

STUDENT NAME______TEACHER______GRADE______

BUS#______PRIMETIME ____am ____pm CAR RIDER____ am _____ pm

PARENT/GUARDIAN______HOME PHONE ______WORK PHONE______

CELL PHONE ______

PRIMARY PHYSICIAN______PHONE ______

SEIZURE SPECIALIST ______PHONE ______

HOSPITAL______

______

SYMPTOMS OF SEIZURES:

Absence (Petit Mal): brief loss consciousness, minimal or no alteration in muscle tone, usually able to

maintain postural control, frequently has minor movements or twitching, often

mistaken for inattention.

Complex Partial Seizures: altered consciousness, memory loss, staring, nonpurposeful movements such

as repeated hand rubbing, buttoning and unbuttoning clothing, lip smacking,

posturing of extremities, vocalization or swallowing, wandering around,

crying, acts of violence.

Tonic-Clonic (Grand Mal): loss of consciousness, falls to floor or ground, arms and legs may become

rigid and move in rhythm with face, breathing may stop for a moment, may

be incontinent of urine and/or feces, may last several minutes, may want to

sleep afterwards.

Please circle the type seizure your child has and indicate symptoms pertinent to your child.

INTERVENTION:

1. Stay with child during and after seizure. Note duration of seizure and type of body movement during

seizure episode. Notify school nurse if in building.

2. Administer any ordered medication. List emergency medication your child uses for a seizure:

______

3. Assist to horizontal position if loss of consciousness occurs. Remove glasses, loosen clothing around neck.

4. Turn on side as soon as able.

5. Clear area around child.

6. DO NOT RESTRAIN MOVEMENT OR PLACE ANYTHING IN MOUTH!

7. Monitor breathing and begin artificial respiration if breathing does not resume spontaneously.

8. If seizure lasts more that 5 minutes or student has one seizure after another without waking, call 911.

9. When seizure is over, allow child to rest and always notify parents.

10. Additional instructions______

______

I authorize the release and exchange of medical and educational information between my child’s physician and school staff

necessary in carrying out this service to my child.

PARENT/GUARDIAN SIGNATURE______DATE______

SCHOOL NURSE______DATE______