Transcription of SEIZURE ACTION PLAN (SAP) - Epilepsy Foundation
1 When rescue therapy may be needed:WHEN AND WHAT TO DO If SEIZURE (cluster, # or length) _____Name of Med/Rx _____ How much to give (dose) _____How to give _____If SEIZURE (cluster, # or length) _____Name of Med/Rx _____ How much to give (dose) _____How to give _____If SEIZURE (cluster, # or length) _____Name of Med/Rx _____ How much to give (dose) _____How to give _____Name: Birth Date: Address: Phone: Emergency Contact/Relationship Phone: SEIZURE ACTION PLAN (SAP)How to respond to a SEIZURE (check all that apply) FFirst aid Stay. Safe. Side. F Notify emergency contact at _____ FGive rescue therapy according to SAP F Call 911 for transport to _____ FNotify emergency contact F Other _____Seizure TypeHow Long It LastsHow OftenWhat HappensFirst aid for any SEIZURE FSTAY calm, keep calm, begin timing SEIZURE FKeep me SAFE remove harmful objects, don t restrain, protect head FSIDE turn on side if not awake, keep airway clear, don t put objects in mouth FSTAY until recovered from SEIZURE FSwipe magnet for VNS FWrite down what happens _____ FOther _____When to call 911 FSeizure with loss of consciousness longer than 5 minutes, not responding to rescue med if available FRepeated seizures longer than 10 minutes, no recovery between them, not responding to rescue med if available FDifficulty breathing after SEIZURE FSerious injury occurs or suspected, SEIZURE in water When to call your provider first FChange in SEIZURE type.
2 Number or pattern FPerson does not return to usual behavior ( , confused for a long period) FFirst time SEIZURE that stops on its own FOther medical problems or pregnancy need to be checkedSeizure InformationSeizure ACTION Plan continuedCare after seizureWhat type of help is needed? (describe) _____When is person able to resume usual activity? _____Health care contactsEpilepsy Provider: Phone: Primary Care: Phone: Preferred Hospital: Phone: Pharmacy: Phone: My signature Date Provider signature Date 2020 Epilepsy Foundation of America, 01/2020 130 SRP/PAB1216 Triggers: _____Important Medical History _____Allergies _____Epilepsy Surgery (type, date, side effects) _____Device.
3 VNS RNS DBS Date Implanted _____Diet Therapy Ketogenic Low Glycemic Modified Atkins Other (describe) _____Special Instructions: _____Medicine NameTotal Daily AmountAmount of Tab/LiquidHow Taken (time of each dose and how much)Daily SEIZURE medicineOther informationSpecial instructions First Responders: _____Emergency Department: _____
