Food Allergy Action Plan - Warrick County School Corporation

1 Name: _____ : _____Allergy to: _____Weight: _____ : [ ] Yes (higher risk for a severe reaction) [ ] NoFor a suspected or active food Allergy reaction:PLACE STUDENT ANTIHISTAMINES, IFORDERED BY PHYSICIAN2. Stay with student; alert emergency contacts. 3. Watch student closely for changes. If symptoms worsen, GIVE AUTHORIZATION SIGNATURE DATE PHYSICIAN/HCP AUTHORIZATION SIGNATURE EPINEPHRINE ambulance with epinephrine. Consider giving additional medications (following or with the epinephrine): Antihistamine Inhaler (bronchodilator) if asthma Lay the student flat and raise legs.

2 If breathing is difficult or they are vomiting, let them sit up or lie on their side. If symptoms do not improve, or symptoms return, more doses ofepinephrine can be given about 5 minutes or more after the last dose. Alert emergency contacts. Transport student to ER even if symptoms resolve. Student should remain in ER for 4+ hours because symptoms may , blue, faint, weak pulse, dizzyMOUTHS ignificant swelling of the tongue and/or lipsOR ACOMBINATIONof mild or severe symptoms from different body Short of breath, wheezing, repetitive coughSKINMany hives over body, widespread rednessGUT Repetitive vomiting or severe diarrheaNOSE Itchy/runny nose, sneezingMOUTHI tchy mouthSKINA few hives, mild itchGUT Mild nausea/discomfortTHROAT Tight, hoarse.

3 Trouble breathing/swallowingOTHERF eeling something bad is about to happen, anxiety, confusionEpinephrine Brand: _____Epinephrine Dose: [ ] mg IM [ ] mg IMAntihistamine Brand or Generic: _____Antihistamine Dose: _____Other ( , inhaler-bronchodilator if asthmatic): _____MEDICATIONS/DOSESSEVERESYMPTOMSMILD SYMPTOMS[ ] If checked, give epinephrine immediately if the allergen was definitely eaten, even if there are no symptoms.[ ] If checked, give epinephrine immediately for ANY symptoms if the allergen was likely : WHEN IN DOUBT, GIVE EPINEPHRINE.

4 !"!"!!"!"!NOTE: Do not depend on antihistamines or inhalers (bronchodilators) to treat a severe Epinephrine.!A special table is requested_____ _____ _____Physician/Provider Signature Parent Signature Principal SignatureEpinephrine:!Epi Pen mg !Epi Pen mg!Auvi-Q mg !Auvi-Q mg!Adrenaclick mg !Adrenaclick mgAntihistamine:Benadryl ! mg ! mg ! mg !25 mg !50 mgOther: _____Other ( ,inhaler-bronchodilator if asthmatic): _____Food Allergy Action PlanEPIPEN (EPINEPHRINE) AUTO-INJECTOR DIRECTIONS1.

5 Remove the EpiPen Auto-Injector from the plastic carrying Pull off the blue safety release Swing and firmly push orange tip against mid-outer thigh. 4. Hold for approximately 10 Remove and massage the area for 10 (EPINEPHRINE INJECTION, USP) DIRECTIONS1. Remove the outer case of Auvi-Q. This will automatically activate the voice Pull off red safety Place black end against mid-outer Press firmly and hold for 5 Remove from /ADRENACLICK GENERIC DIRECTIONS1. Remove the outer Remove grey caps labeled 1 and 2.

6 3. Place red rounded tip against mid-outer Press down hard until needle Hold for 10 seconds. Remove from DIRECTIONS/INFORMATION(may self-carry epinephrine, may self-administer epinephrine, etc.):22233412 EMERGENCY CONTACTS CALL 911 RESCUE SQUAD: _____DOCTOR: _____ PHONE: _____PARENT/GUARDIAN: _____ PHONE: _____OTHER EMERGENCY CONTACTSNAME/RELATIONSHIP: _____ PHONE: _____NAME/RELATIONSHIP: _____PHONE: _____Treat student before calling Emergency Contacts. The first signs of a reaction can be mild, but symptoms can get worse quickly.

7 !The School may post this form in a visible location. !If the patient presents to the emergency department, please monitor the patient for a biphasic reaction for at least ____ hours.!Two doses of Epinephrine should be kept at School in case a repeat dose is needed.!The student is capable and has been instructed in the proper method of self administering the medications named above and may carry the medicines during School hours.