plan of action forms - southern 7 health department

0

Southern Seven Head Start/Early

Head Start Plan of Action Forms

Grantee and delegate agencies operating center-based programs must establish and implement policies and procedures to respond to medical and dental health emergencies with which all staff are familiar and trained.

Compiled By the Health & Nutrition Specialist Last Updated: July, 2018

1

Table of Contents

Plan of Action: Asthma/Breathing Difficulties .................................................................................. 2

Plan of Action: Allergy ................................................................................................................... 7

Plan of Action: Diabetes .............................................................................................................. 15

Hyperglycemia: ....................................................................................................................... 16

Hypoglycemia: ......................................................................................................................... 16

Plan of Action: Seizures ............................................................................................................... 22

Other Health Conditions: ............................................................................................................. 26

Works Cited ................................................................................................................................ 30

2

Plan of Action: Asthma/Breathing Difficulties

Asthma is a chronic inflammatory disease of the respiratory system that causes the airways of the

lungs to swell, tighten and constrict. During an asthma episode three things can happen:

Swelling of the airways (inflammation)

Squeezing: the air passages are squeezed together by the muscles that surround the outside

of each airway (constriction)

Clogging: the mucus blocks the airways and thus allows less air to pass through the airways

This combination of swelling, squeezing, and clogging dramatically reduces the size of the airways.

Quick Facts

Asthma is one of the most common chronic diseases nationwide, impacting the lives and

families of over 7 million children.

Asthma is the third-ranking cause of hospitalization among children under 15.

An average of one out of every 10 school-aged children has asthma.

10.5 million school days are missed each year due to asthma.

Checklist

Have parent/guardian fill out and sign Southern Seven Head Start/Early Head Start Asthma

Plan of Action Form.

If medication may be needed fill out Medication Administration Form located on the back of

the Asthma Action Plan.

If asthma attack occurs follow procedure outlined in your site’s Emergency/Medical

Management Plan.

Afterwards complete the Symptom Record Form, send a copy to the Health & Nutrition

Specialist and file the original at your center.

3

Southern Seven Head Start/Early Head Start ASTHMA PLAN OF ACTION FORM

Child’s Name: Birthdate: Site:

TO BE COMPLETED BY PARENT/GUARDIAN

What triggers your child’s asthma?

Pollens Dust Weather Animals Exercise Illness Other:

Usual symptoms? Coughing Shortness of Breath Wheezing Tightness of Chest Difficulty Speaking Other:

Increased symptoms? Coughing Shortness of Breath Wheezing Tightness of Chest Difficulty Speaking Other:

Parent/Guardian Signature: Date:

TO BE COMPLETED BY THE HEALTH CARE PROVIDER

Asthma severity: Mild Intermittent Mild Persistent Moderate Persistent Severe Persistent Other:

Asthma Medication is prescribed and it is required at the site.

NO asthma medication is required at the site.

GREEN (GO) ZONE Breathing is good

Sleep through the night

No cough or wheezing

Can play/active

Preventive Medicines:

Medicine: Dose: When: Device: Other Instructions:

YELLOW (CAUTION) ZONE First sign of cold

Cough

Mild wheeze

Cough at night

Exposure to known trigger

Tight chest

1. GIVE QUICK RELIEF MEDICINE DEVICE DOSE WHEN

Albuterol (Proventil, Ventolin) Xopenex Other:

Inhaler & spacer w/mask Nebulizer w/mask Nebulizer w/mouthpiece

Every 4-6 hrs. as needed for symptoms

Other:

2. CALL PARENT(S)/GUARDIAN(S) 3. If child does not improve within 10-20 minutes, repeat treatment & call parent/guardian to pick-up child. 4. If child gets worse GO TO RED ZONE.

RED (DANGER) ZONE Medicine is not helping

Breathing is hard & fast

Nose opens wide

Ribs show

Lips and/or Fingernails blue

Trouble walking and talking

1. GIVE QUICK RELIEF MEDICINE DEVICE DOSE WHEN

Albuterol (Proventil, Ventolin) Xopenex Other:

Inhaler & spacer w/mask Nebulizer w/mask Nebulizer w/mouthpiece

GIVE NOW!!!!

2. CALL 911 if child does not improve within 5-10 minutes, or is getting worse. 3. CALL PARENT(S)/GUARDIAN(S).

Other: See Health Care Provider’s Plan of Action if available.

Health Care Provider Signature: Date:

Staff Signature: Date:

Site Supervisor Signature: Date:

Attach Child’s

Picture Here

4

Southern Seven Head Start/Early Head Start PARENT/GUARDIAN’S REQUEST

FOR MEDICATION ADMINISTRATION

All Medication Must Be In The Original Container!

CHILD’S INFORMATION

Name:

Address:

PARENT/GUARDIAN INFORMATION

Mother’s Name: Phone #: Work #:

Address:

Father’s Name: Phone #: Work #:

Address:

ADDITIONAL EMERGENCY CONTACT

Name: Relationship: Phone #:

PHYSICIAN INFORMATION

Name: Phone #:

Office Address:

PRESCRIPTION INFORMATION

Pharmacy: Date:

Prescription Number: Diagnosis:

Drug: Dosage:

Frequency of Administration:

Directions for Administration:

Possible Side Effects:

I hereby request Head Start to administer the above medication to my child ______________________. I will hold and save the Head Start Program from and against any and all actions or cause of action, claims, demands, and liabilities, loss, damage, or expense of whatsoever kind and nature which the Head Start Program shall or may at any time sustain or incur by reason or in consequence of the administrating of the medication to my child.

Parent/Guardian’s Signature: Date:



6

Asthma/Breathing Difficulties Management Plan

STAY CALM: Don’t Panic. Getting upset only makes things worse.

Remove child from area of trigger and have child sit upright.

Encourage use of deep breathing and relaxation exercises to avoid panic.

Designate 2 individuals to care for child in a private area. Never leave the child alone.

Use the Asthma Action Plan.

Take medicines as directed: Take quick-relief medicine if breathing is labored. No medication

is to be given unless the child has a PRN inhaler or nebulizer.

Child should respond to treatment within 15-20 minutes.

If NO change is observed or breathing becomes significantly worse, call for emergency help

and contact parent immediately.

Make sure someone reassures the children that were present when the attack began and

incorporate the experience into a health lesson.

Seek Immediate Emergency Care If:

! Coughs constantly

! Is unable to speak in complete sentences without taking a breath

! Has lips, nails, mucous membranes that are gray or blue

! Demonstrates severe retractions and/or nasal flaring

! Is vomiting persistently

! Has pulse of greater than 120 per minute

! Has respirations of greater than 30 per minute

! Is severely restless

! Shows no improvements after 15 minutes

7

Plan of Action: Allergy

The job of the body’s immune system is to identify and destroy germs (such as bacteria or viruses)

that make you sick. A food allergy results when the immune system mistakenly targets a harmless

food protein – an allergen – as a threat and attacks it.

Although nearly any food is capable of causing an allergic reaction, only eight foods account for 90

percent of all food-allergic reactions in the United States. These foods are:

Peanut

Tree nuts

Milk

Egg

Wheat

Soy

Fish

Shellfish

Symptoms typically appear within minutes to several hours after eating the food to

which you are allergic. Keep in mind that children may communicate their symptoms in

a different manner than adults.

Mild symptoms may include one or more of the following:

Hives (reddish, swollen, itchy

areas on the skin)

Eczema (a persistent dry, itchy

rash)

Redness of the skin or around the

eyes

Itchy mouth or ear canal

Nausea or vomiting

Diarrhea

Stomach pain

Nasal congestion or a runny nose

Sneezing

Slight, dry cough

Odd taste in mouth

Uterine contractions

Severe symptoms may include one or more of the following:

Obstructive swelling of the lips,

tongue, and/or throat

Trouble swallowing

Shortness of breath or wheezing

Turning blue

Drop in blood pressure (feeling

faint, confused, weak, passing

out)

Loss of consciousness

Chest pain

A weak or “thread” pulse

Sense of “impending doom”

9

Anaphylaxis

Anaphylaxis is an extreme and severe allergic reaction. The whole body is affected, often within minutes of exposure to the substance which causes the allergic reaction (allergen) but sometimes after hours. During anaphylaxis, allergic symptoms can affect several areas of the body and may threaten breathing and blood circulation. Food allergy is the most common cause of anaphylaxis,

although several other allergens – insect stings, medications, or latex – are other potential triggers.

Epinephrine (adrenaline) is a medication that can reverse the severe symptoms of anaphylaxis. It is given as a “shot” and is available as a self-injector, also known as an epinephrine auto-injector, that can be carried and used if needed. Epinephrine is a highly effective medication, but it must be administered promptly during anaphylaxis to be most effective. Delays can result in death in as little as 30 minutes. Even if epinephrine is administered promptly and symptoms seem to subside completely, the individual who was treated with epinephrine should always be taken to the emergency room for further evaluation and treatment.

Quick Facts

Food allergy is a serious medical condition affecting up to 15 million people in the United

States, including 1 in 13 children.

In the U.S., food allergy symptoms send someone to the emergency room every three

minutes.

People who have both asthma and a food allergy are at greater risk for anaphylaxis.

Checklist

Have parent/guardian fill out and sign Southern Seven Head Start/Early Head Start Allergy

Plan of Action Form.

If anaphylaxis is a possibility FARE Food Allergy & Anaphylaxis Emergency Care Plan may be

needed. Contact Health & Nutrition Specialist for further instruction.

If medication may be needed have parent fill out Parent/Guardian’s Request for Medication

Administration Form.

If an allergic reaction occurs follow procedure outlined in your site’s Emergency/Medical

Management Plan.

Afterwards, complete Symptom Record Form, send a copy to the Health & Nutrition Specialist,

and file the original at your center.

10

Southern Seven Head Start/Early Head Start ALLERGY PLAN OF ACTION FORM



What things cause this child’s allergic reaction?

MILD SYMPTOMS Nose – Itchy or runny nose, sneezing Mouth – Itchy mouth

Skin – A few hives, mild itch Gut – Mild nausea or discomfort

Other:

ACTION FOR MILD SYMPTOMS

1. Give: Rx Antihistamine Other:

2. Call parent/guardian.

3. If condition does not improve within 10 minutes follow the Action for Severe Symptoms below. *For Mild Symptoms from more than one system area, give Epinephrine.

SEVERE SYMPTOMS Lung – Shortness of breath, wheezing, repetitive cough

Heart – Pale or bluish skin, faintness, weak pulse, dizziness

Throat – Tight or hoarse throat, trouble breathing or swallowing

Mouth – Significant swelling of the tongue or lips

Skin – Many hives over body, widespread redness

Gut – Repetitive vomiting, severe diarrhea

Other:

ACTION FOR SEVERE SYMPTOMS

1. Give: Epinephrine Other:

2. Call 911.

3. Call parent/guardian.

Is anaphylaxis a possibility? Yes No

Medications AT SCHOOL? Yes No If yes, what medications? Epinephrine Rx Antihistamine Other:






Attach Child’s

Picture Here

11





Name:

Address:



Address:


Address:




Name: Phone #:

Office Address:


Pharmacy: Date:


Drug: Dosage:








14

Allergic Reaction/Anaphylaxis Management Plan


Follow Allergy Action Plan.

Mild Symptoms:

o Antihistamines may be given if ordered by a healthcare provider. No medication is to be

given unless the child has a PRN on file.

o Stay with child and alert emergency contacts.

o Watch child closely for changes. If symptoms worsen, administer epinephrine

immediately and call 911.

Severe Symptoms:

o Inject Epinephrine Immediately.

o Call 911 – Tell them the child is having anaphylaxis and may need more epinephrine

when they arrive.

o Consider giving additional medications following epinephrine if child has PRN for

antihistamine or inhaler.

o Lay child flat, raise legs and keep warm. If breathing is labored or they are vomiting, let

them sit up or lie on their side.

o IF SYMPTOMS DO NOT IMPROVE OR SYMPTOMS RETURN – MORE DOSES OF

EPINEPHRINE CAN BE GIVEN ABOUT 5 MINUTES OR MORE AFTER THE LAST DOSE.

o Alert Emergency Contacts.

o Transport to ER even is symptoms resolve.

Make sure someone reassures the children that were present when the attack began and

incorporate the experience into a health lesson.

Severe Symptoms

! Short of breath, wheezing, or repetitive cough

! Pale, blue, faint, weak pulse, or dizzy

! Throat is tight, horse, or has trouble breathing/swallowing

! Mouth has significant swelling of the tongue and/or lips

! Skin has many hives over body or widespread redness

! Repetitive vomiting or severe diarrhea

! Feeling something bad is about to happen, anxiety, and confusion

! Or a combination of symptoms from different areas

15

Plan of Action: Diabetes

Diabetes is a problem with the body that causes blood glucose (sugar) levels to rise higher than

normal. This is also called hyperglycemia.

Type I Diabetes: Type 1 diabetes is usually diagnosed in children and young adults, and was

previously known as juvenile diabetes. Only 5% of people with diabetes have this form of the

disease. In type 1 diabetes, the body does not produce insulin. Insulin is a hormone that is needed to

convert sugar, starches and other food into energy needed for daily life.

At its core, proper type 1 diabetes management is composed of a handful of elements: blood glucose

control and insulin management, exercise, nutrition and support.

Medication: Type I Diabetes requires multiple daily injections with insulin pens or syringes or

an insulin pump.

Exercise: With type 1, it’s very important to balance insulin doses with the food eaten and the

activity performed. Sometimes people experience a drop in blood glucose during or after

exercise, so it is very important to monitor blood glucose, take proper precautions, and be

prepared to treat hypoglycemia (low blood glucose).

Nutrition: How much and what type of carbohydrate foods are important for managing

diabetes. The balance between how much insulin is in the body and the carbohydrate eaten

makes a difference in blood glucose levels. Most diabetics have individual meal plans that need

to be followed.

Type II Diabetes: Type 2 diabetes is the most common form of diabetes. In Type 2 diabetes the

body does not use insulin properly. This is called insulin resistance. At first, the pancreas makes extra

insulin to make up for it. But, over time it isn’t able to keep up and can’t make enough insulin to keep

blood glucose at normal levels. Management of Type 2 Diabetes includes healthy eating, regular

exercise, blood glucose monitoring, and sometime medication. Some people who have type 2

diabetes can achieve their target blood sugar levels with diet and exercise alone, but many also need

diabetes medications or insulin therapy.

16

Quick Facts

Type 1 diabetes can also be called insulin-dependent diabetes because people with type 1

must take insulin in order to live.

With tight blood glucose control, a person with diabetes can avoid many of the short- and

long-term complications associated with diabetes.

Hyperglycemia:

Hyperglycemia is the technical term for high blood glucose (blood sugar). High blood glucose

happens when the body has too little insulin or when the body can't use insulin properly.

The signs and symptoms include the following:

High blood glucose

High levels of sugar in the urine

Frequent Urination

Increased Thirst

Dry Mouth

Tired

Hunger

Headache

Ketones in Urine

*If symptoms persist they can lead to nausea, vomiting, stomach pain, and fruit

smelling breath

Hypoglycemia:

Hypoglycemia is a condition characterized by abnormally low blood glucose (blood

sugar) levels, usually less than 70 mg/dl. However, it is important talk with a child’s

parent/guardian about individual blood glucose targets, and what level is too low that

specific child.

Signs and Symptoms of Hypoglycemia (happen quickly):

Shakiness Nervousness or anxiety

Sweating, chills and clamminess

Irritability or impatience

Confusion, including delirium

Rapid/fast heartbeat

Lightheadedness or dizziness

Hunger and nausea

Sleepiness

Blurred/impaired vision

Tingling or numbness in the lips

or tongue

Headaches

Weakness or fatigue

Anger, stubbornness, or sadness

Lack of coordination

Nightmares or crying out during

sleep

Seizures

Unconsciousness

17

Checklist

Have parent/guardian fill out and sign Southern Seven Head Start/Early Head Start Diabetes

Plan of Action Form, Hyperglycemia Plan of Action Form, and Hypoglycemia Plan of Action

Form.

Contact the Health & Nutrition Specialist to schedule a diabetes training for site staff


Administration Form

If hypoglycemia or hyperglycemia occurs follow procedure in plans


and file the original at your center

18

Southern Seven Head Start/Early Head Start DIABETES PLAN OF ACTION FORM

Child’s Name: Site:

1) Diagnosis: Type I Diabetes Type II Diabetes Pre-Diabetes

Other Condition Requiring Glucose Monitoring:

2) When should blood sugar monitoring be done?

As needed for signs/symptoms of low or high blood sugar

Before Feeding

As needed for signs/symptoms of illness

Other:

3) Diet Requirements:

No Concentrated Sweet Diet

Carbohydrate Count: carbs/meal

Other:

Does the child require a SCHEDULED snack at any time during the school

day? Yes No

If yes, do they need insulin with the snack? Yes No

How many units of insulin? Other: See Health Care Provider’s Plan of Action if available.

Plan of Action:





Attach Child’s

Picture Here

19

Southern Seven Head Start/Early Head Start HYPERGYLCEMIA (HIGH BLOOD SUGAR)

PLAN OF ACTION FORM


Signs & Symptoms:

dry mouth; increased urination; tired; thirsty; sores or infections that will not heal; hungry; sleepy; dry, itchy skin; headache *If symptoms persist, they can lead to nausea, vomiting, stomach pain, fruity smelling breath

High Blood Sugar for this Child Requiring the Following Interventions is Greater Than: (Fill in the number)

Interventions:

Encourage extra liquids without sugar such as water. No extra juice or milk.

Allow frequent trips to the restroom.

Ketone monitoring: (If child is positive for ketones, MUST notify parent/guardian)

Other: Other: See Health Care Provider’s Plan of Action if available.

Plan of Action:





Attach Child’s

Picture Here

20

Southern Seven Head Start/Early Head Start HYPOGYLCEMIA (LOW BLOOD SUGAR)

PLAN OF ACTION FORM


Signs & Symptoms:

dizzy; crying; headache; clammy sweat; nervous; unable to think clearly; shaky; blurry vision; restless; weak; combative; unusually sleepy; pale; pounding heart; confused or disoriented; stumbling around; change in personality (mean/hateful)

Low Blood Sugar for this Child Requiring the Following Interventions is Lower Than: (Fill in the number)

Interventions:

Follow 15/15 rule: Give equivalent of 15 grams of carbohydrates. If no improvement within 15 minutes, then repeat simple sugar. Follow immediately with a 15 gram snack of complex carbohydrate OR

lunch.

Staff should check blood sugar 30 minutes after initial treatment.

Call parent if the blood sugar does not rise above mg/dl.

Allow 30-60 minutes for complete recovery before resuming normal school activities. It may not be necessary to send the student home.

Other: Other: See Health Care Provider’s Plan of Action if available.

Plan of Action:





Attach Child’s

Picture Here

21

Hyperglycemia Management Plan


Follow Hyperglycemia Treatment steps listed in child’s action plan

If child uses a pump, check to see if pump is connected properly and functioning.

Give child plenty of water to drink.

Allow extra trips to the restroom.

Re-check glucose every 2 hours to determine if glucose is reaching normal level.

Restrict physical activity.

Notify parent/guardian immediately if ketones are present.

Moderate Hypoglycemia Management Plan


Provide simple sugar equal to grams of carbohydrates in child’s action plan.

Wait 15 minutes.

Recheck blood glucose level.

Repeat if blood glucose level is still low.

Follow immediately with a 15 gram complex carbohydrate snack or next meal.

Contact the student’s parents/guardian.

Severe Hypoglycemia Management Plan


Position the student on his or her side.

Do not attempt to give anything by mouth.

Follow child’s action plan.

While treating, have another person call 911 (Emergency Medical Services).

Contact the student’s parents/guardian.

Stay with the student until Emergency Medical Services arrive.

Hypoglycemia Severe Symptoms

! Inability to eat or drink

! Unconscious

! Unresponsive

! Seizure activity or Convulsions

22

Plan of Action: Seizures

Seizures are caused by abnormal electrical activity in the brain. Someone having a seizure might

collapse, shake uncontrollably, or have another brief disturbance in brain function, often with a loss

of or change in consciousness.

Seizures can be frightening, but most last only a few minutes, stop on their own, and are not life

threatening.

Seizures that happen more than once or over and over might indicate the ongoing condition epilepsy.

Some children under 5 years old have febrile seizures, which can develop during a medium or high

fever — usually above 100.4°F (38°C). While terrifying to parents, these seizures are usually brief

and rarely cause any serious or long-term problems.

Quick Facts

You can’t swallow your tongue during a seizure. It's physically impossible.

You should NEVER force something into the mouth of someone having a seizure.

Epilepsy is NOT rare. There are more than twice as many people with epilepsy in the US as the

number of people with cerebral palsy (500,000), muscular dystrophy (250,000), multiple

sclerosis (350,000), and cystic fibrosis (30,000) combined.

Checklist

Have parent/guardian fill out and sign Southern Seven Head Start/Early Head Start Seizure

Plan of Action Form

If medication may be needed fill out the Medication Administration Form located on the back

of the Seizure Plan of Action form.

If seizure occurs follow procedure outlined in your site’s Emergency/Medical Management Plan



23

Southern Seven Head Start/Early Head Start SEIZURES PLAN OF ACTION FORM



Type of Seizure Length Frequency Description

For Febrile Seizure: If child has a temperature of degrees Fahrenheit or higher then administer fever reducing medication per instruction on the Authorization to Administer Prescription Medication form and call parent to pick-up.

Possible triggers or warning signs:

SEIZURE FIRST AID

Stay calm and track time Keep child safe Do not restrain Do not put anything in mouth Stay with child until fully conscious Record seizure in log

Protect head (tonic-clonic) Keep airway open/watch breathing (tonic-clonic)

Turn child on side (tonic-clonic)

SEIZURE ACTION PLAN

1. Notify parent or emergency contact if unable to reach call 911.

2. Administer emergency medications as indicated if applicable.

3. Other: See Health Care Provider’s Plan of Action if available.

A SEIZURE IS GENERALLY CONSIDERED AN EMERGENCY WHEN:

Convulsive (tonic-clonic) seizure lasts longer than 5 minutes.

Student has repeated seizures without regaining consciousness.

Student is injured or has diabetes.

Student has a first-time seizure.

Student has breathing difficulties.





Attach Child’s

Picture Here

24





Name:

Address:



Address:


Address:




Name: Phone #:

Office Address:


Pharmacy: Date:


Drug: Dosage:








25

Seizure Management Plan

If Generalized Seizure Occurs:

If falling, assist student to floor, turn to side.

Loosen clothing at neck and waist; protect head from injury.

Clear away furniture and other objects from area.

Have another classroom adult direct students away from area.

Time the seizure.

Allow seizure to run its course; DO NOT restrain or insert anything into student’s

Do not try to stop purposeless behavior.

During a general or grand mal seizure expect to see pale or bluish discoloration of the skin or

lips. Expect to hear noisy breathing.

If Smaller Seizure Occurs: (lip smacking, behavior outburst, staring, twitching of mouth/hands)

Assist student to comfortable, sitting position.

Time the seizure.

Stay with student, speak gently, and help student get back on task following seizure.

Seizure Is Considered An Emergency When:

! A convulsive (tonic-clonic) seizure lasts longer than 5 minutes

! There are repeated seizures without regaining consciousness

! It’s a first-time seizure

! The child is injured or has diabetes

! The child has breathing difficulties

! The seizure is in water

26

Other Health Conditions:

Checklist

Have parent/guardian fill out and sign Southern Seven Head Start/Early Head Start Other

Health Conditions Plan of Action Form


Administration Form

If an incidence occurs related to the specific condition(s) follow the Plan of Action.



27

Southern Seven Head Start/Early Head Start OTHER HEALTH CONDITIONS

PLAN OF ACTION FORM


Diagnosis:

Latex Allergy? Yes No

Precautions at School:

Restrictions/Exclusion at School:

Other Comments:

Plan of Action:






Attach Child’s

Picture Here

28





Name:

Address:



Address:


Address:




Name: Phone #:

Office Address:


Pharmacy: Date:


Drug: Dosage:








29

Southern Seven Head Start/Early Head Start SYMPTOM RECORD

Child’s Name: Date:

MAIN SYMPTOM:

When did it began? How long has it lasted?

How much? How often?

Is it staying constant, getting better or worse?

OTHER SYMPTOMS/COMPLAINTS:

General appearance (ie. comfort, mood, behavior, activity level, appetite):

CHECK () THE SYMPTOMS

Breathing: coughing wheezing breathing fast difficulty breathing other:

Skin: pale flushed rash sores swelling bruises itchiness other:

Vomiting (number of times): Diarrhea (number of times): Urine:

Eyes: pink/red watery discharge crusty swollen other:

Nose: congested runny other:

Ears: pulling at ears discharge other:

Mouth: sores drooling difficulty swallowing other:

Odors (ie. Breath, stool):

Temperature: axillary oral rectal other:

WHAT HAS BEEN DONE

Comfort: Rest:

Liquids Name: Amount: Time:

Food Name: Amount: Time:

Medications (see medication administration procedure)

Name: Amount: Time:

Emergency measures:

Who was called and when (ie. parent/guardian, emergency contact person, health consultant, child’s health provider, emergency medical services)?

Signature: Date:

30

Works Cited

American Diabetes Association. (2015). ADA. Retrieved from American Diabetes Assocation:

http://www.diabetes.org

American Lung Associate. (2015). Learning More About Asthma. Retrieved from American Lung

Association: Fighting for Air: http://www.lung.org/lung-disease/asthma/learning-more-about-

asthma/

Food Allergy & Research Education. (2015). FARE. Retrieved from Food Allergy & Anaphylaxis

Emergency Care Plan: https://www.foodallergy.org/faap

Kid's Health. (2015). Seizure Basics. Retrieved from Kid's Health:

http://kidshealth.org/parent/firstaid_safe/emergencies/seizure.html#

National Heart, Lung, & Blood Institute. (2007). NIH. Retrieved from Asthma Action Plan:

https://www.nhlbi.nih.gov/files/docs/public/lung/asthma_actplan.pdf

PPMD. (n.d.). Seizure Action Plan for Schools. Retrieved from Parent's Place of Maryland:

http://ppmd.org/wp-content/uploads/2014/03/WritableSeizure_Action_Plan.pdf

plan of action forms - southern 7 health department

Documents