Great Falls Public Schools
P.O. Box 2429
Great Falls, Montana 59403
Phone: (406) 268-6025
Nursing Dept: (406) 268-7700
Fax: ( 406) 268-7004
EMERGENCY CARE PLAN
Date: ______________________
Student Name: ____________________________
Birth Date: _____________ Age: ______
School: __________________________________ Grade: ______________
Weight:__________
Medical condition:
Allergy:
Warning signs:
Mouth: itching, tingling, swelling of mouth, tongue, lips
Skin: hives, itchy rash, swelling of the face or extremities
Gut: nausea, abdominal cramps, vomiting, diarrhea
Throat: tightening of the throat, hoarseness, hacking cough, clearing throat.
Lungs: shortness of breath, repetitive coughing, wheezing,
Heart: weak or thready pulse, pale, blue, dizziness, confusion
Steps to be taken for allergic reaction:
FOR MILD REACTION (localized reaction in one body system)
1. Give antihistamine. ( Benadryl) Dose:___________
2. Notify parents.
FOR TREATMENT OF ANAPHYLAXIS
1. Administer Epi Pen. (**Do not delay administration of epinephrine for any signs of anaphylaxis**)
**Location of Epi Pen(s):
2. Call 911.
3. Give Benadryl if student has not received dose yet and if they are able to swallow. (Dose:_______)
4. Notify Parents
Other Medications taken by student:
Allergies to Medications:
School Day Accommodations:
-Does this student use the school bus for transportation? Y / N
-Does this student need to sit at a nut free table? Y / N
NA
Emergency contact:
Name: ________________________ Relationship: ___________________
Phone: _______________________
Planning Participants (signature):
___________________________________
Doctor
__________________________________
Parent/Guardian
___________________________________
Parent/ Guardian
__________________________________
Building Administrator
___________________________________
Teacher
__________________________________
School Nurse
__________________________________
Teacher
____________________________________
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