Individual Health Care Plan
Student Name:
Date of Birth
IEP
504
Medical Diagnosis: Food Allergy - Risk for Anaphylaxis: Severe Allergic Reaction
Identified Allergens:
Nursing Assessment
� Review all information provided by parents and health records or orders from current healthcare providers.
� Diagnosis of an allergy from a Healthcare Provider present in student’s school health record
� Student’s known allergies:
� Student’s reaction to known allergies:
� Age when allergy was first discovered:
� Other risk factors (ie: asthma):
� Current allergy management plan:
� Other health conditions
� Does student take any other medication
Other
Nursing Diagnosis
� Risk for allergy response related to exposure to allergen(s). List allergens:
� Noncompliance related to non-adherence behavior
� Risk for shock related to exposure to allergen
Other
Nursing Interventions
The School Nurse will:
� determine potential sources of allergens in school settings. List allergens:
� collaborate with designated school personnel to eliminate potential sources of allergens in school settings
� provide in-service for designated school staff about allergic reaction/anaphylaxis
� encourage student self-advocacy and immediate communication with school personnel
� monitor indoor and outdoor school environment for potential allergens
Other
Expected Student Outcomes
The student will:
� identify triggers that can cause potential severe reaction.
� identify his or her symptoms of an allergic reaction (from mild to severe)
� describe steps to take if an allergic reaction occurs.
Other
Student Specific Notes
School Nurse:
Date Initiated:
Last Reviewed/Updated:
Webster Public Schools Emergency Action Plan
Student Name
Date of Birth
IEP
504
Medical Diagnosis: Food Allergy - Risk for Anaphylaxis: Severe Allergic Reaction
Identified Allergens:
If ingestion of known allergen is known or suspected, or if student presents with symptoms, notify School Nurse
immediately.
Student
Specific EpiPen’s are in the Emergency
Allergy Cabinet in the Nursing Office and can
administered by any trained staff.
be
If the student does not have a prescribed
EpiPen, school stock EpiPen may be used by
a Registered Nurse ONLY.
Classroom/School Accommodations:
● In class snacks will be limited to nut-free
items following the districts Life Threatening
Allergy
Policy
● Breakfast in the Classroom will prepare allergy bags for students who have allergies with items that do not
contain the known allergen for the student.
● Nut free lunch tables are available in the cafeteria. Student DOES or DOES NOT need to sit at this table.
● Cafeteria staff will prepare specific lunches for students who have allergies that do not contain the known
allergen for the student.
● Other:
School Nurse:
Copy to Teacher(s):
Date Initiated:
UA Staff:
Last Updated: