HEALTH MANAGEMENT PLAN for SEIZURES
NAME:
DOB:
CONTACT NAME AND NUMBER:
GRADE:
EMERGENCY ACTION PLAN (EAP)
*A signed medication PRESCRIBER/PARENT AUTHORIZATION (PPA) FORM is required for each medication*
Is a medication PRESCRIBER/PARENT AUTHORIZATION (PPA) on file for this student?  YES  NO
If student “self-carries” medication, a “back up” medication may be kept in clinic?
 YES  NO Does student
experience an AURA before seizures?  YES  NO If YES what?
Behavior/activity student usually exhibits during seizures:  Stiffening & jerking movements
 Tremors or twitching  Repeated blinking of eyes
Rapid eye movements
 Lip smacking
 Tongue movements
Repeated non-purposeful
Staring
Other: ____________________________________________________________________
IF YOU SEE THIS…
Onset of Seizure Activity
DO THIS…
If VNS: 1st swipe with magnet per prescriber’s order. Follow steps below and repeat
VNS as ordered
If NO VNS, follow steps below:
•
Student has *VNS?  YES  NO
Swipe magnet at onset of seizure and repeat
every ____ seconds times_____
•
•
Seizure Activity Continues
*Klonopin/Clonazepam ordered at school?  YES
 NO
Klonopin/Clonazepam ____mg administer after
____ minutes
HS-P14-F8
Remain with student and provide verbal reassurance, notify School Nurse
Provide privacy, do not restrain student, do not put anything in student’s
mouth
Note time at onset of seizure activity, duration, activity noted and document on
seizure log
Seizure activity stops, contact Parent/Guardian/Emergency Contact to inform of
seizure
•
If seizure activity continues, call for School Nurse and continue to monitor student
Ease student to the floor and place student in side-lying position
Cushion student’s head and remove surrounding objects that could cause injury
revised 04/24/17
© Created by Huntsville City Schools
or if ___ seizures within ____ minutes
Medication not required on the bus
*Diastat ordered at school?
 YES
 NO
Diastat ____mg administer after ____ minutes
Medication Assistant/Licensed Nurse/Parent Guardian will administer
Klonopin/Clonazepam per PPA
Licensed Nurse or Parent/Guardian will administer Diastat or Versed per PPA
Continue to document and note time emergency medication was given
or if ___ seizures within ____ minutes
Call 911 if emergency medication is given, student injury or for seizure > _____ min
Medication not required on the bus
Call Parent/Guardian/Emergency Contact
*Versed ordered at school?
 NO
Versed ____mg administer after ____
minutes or if ___ seizures within ____
minutes Medication not required on
the bus
 YES
If NOT transported to ER and emergency medication was administered,
Parent/Guardian/Emergency Contact will take student home
IHP
SECTION III – SCHOOL NURSE
FOR SCHOOL USE ONLY
THAT APPLY
PLEASE, CHECK ALL
SEIZURE DISORDER, also known as Epilepsy, is a disorder of the central nervous system characterized by a tendency for recurrent seizures. The term "seizure" refers to sudden,
uncontrolled episodes of abnormal behavior related to abnormal electrical discharges in the brain. A seizure is a symptom of the disorder just as fever is a symptom of infection.
Seizure disorders are not contagious or a sign of mental illness. Only in rare cases do seizures require emergency intervention. Most seizures are over in a few minutes and do not
require medical follow up.
MEDICATION(S) AT SCHOOL:
 VNS magnet: Carried on person?  Yes  No Self-administer?  Yes 
No
 Klonopin:
Carried on person?  Yes  No Self-administer?  Yes 
No
 Diastat:
Carried on person?  Yes  No
 Versed:
Carried on person?  Yes  No
CLASSROOM:
 Allow student to self-limit physical activity as needed
 Observe student for evidence of seizure activity. If seizure activity is noted,
trained
adult will administer VNS swipe, follow the student’s Emergency
Action Plan
(EAP), contact School Nurse
Considerations for outdoor activities
 None required  Other:
_____________________________________________
Additional Instructions:
_______________________________________________
FIELD TRIPS:
 Allow student to self-limit physical activity as needed
Considerations for outdoor activities
HS-P14-F8
revised 04/24/17
POTENTIAL SIDE EFFECTS: (Notify School Nurse)
 Do not place magnet close to electronic items
 Drowsiness  Slow heart rate  Respiratory depression
Other: ____________________________________________
PHYSICAL EDUCATION and/or RECESS:
 Allow student to self-limit physical activity as needed
 Observe student for evidence of seizure activity. If seizure activity is noted,
trained adult will administer VNS swipe, follow the student’s Emergency Action
Plan (EAP), contact School Nurse
Considerations for outdoor activities
 None required  Other:
____________________________________________
Additional Instructions:
______________________________________________
EXTRACURRICULAR PLAN/AFTERSCHOOL CARE:
 Allow student to self-limit physical activity as needed
Considerations for outdoor activities
© Created by Huntsville City Schools
 None required  Other:
_____________________________________________
 Observe student for evidence of seizure activity. If seizure is noted, follow the
student’s Emergency Action Plan (EAP) and PPA, contact School Nurse
 Student has VNS?  Yes  No Trained adult will administer swipe
 Student has Klonopin?  Yes  No
Medication Assistant/Parent/Guardian/Licensed Nurse will administer
 Student has Diastat?  Yes  No or Student has Versed?  Yes  No
If yes, student will be accompanied by Licensed Nurse or Parent/Guardian
 Emergency Medication and/or VNS magnet should NOT be left in a backpack
on
the bus or with a Medication Assistant/Licensed Nurse who is not with the
student
If student IS authorized to self-carry emergency medication:
 Student will keep medication and/or VNS magnet on person at all times
 Trained adult will swipe VNS with magnet
 Klonopin/Clonazepam, if ordered by prescriber, will be administered by
Medication
Assistant/Parent/Guardian/Licensed Nurse
 Diastat or Versed, if ordered by prescriber, will be administered by
Parent/Guardian or Licensed Nurse
Student is NOT authorized to self-carry emergency medication:
 Medication Assistant, Parent/Guardian or Nurse will accompany trip with
medication & orders to be kept on person
 Trained adult will swipe VNS with magnet
 Klonopin/Clonazepam, if ordered by prescriber, will be administered by
Medication
Assistant/Parent/Guardian/Licensed Nurse
 Diastat or Versed, if ordered by prescriber, student will have ready access to
Parent/Guardian or Licensed Nurse for duration of the trip/event
 Call 911 immediately if emergency medication is given, student injury or
seizure
> 5 min; then contact Parent/Guardian
BUS PLAN:
VNS/Emergency medication will not be available for administration during
transport unless student is authorized to self-carry
 Licensed Nurse or Parent/Guardian will not be available on the bus
 Student will keep medication on person at all times if authorized
 Driver will pull over, activate EMS, call Parent/Guardian and remain with
student
 Other:
___________________________________________________________
Written Notes/Addendum to Plan of Care
Date
HS-P14-F8
 None required  Other:
____________________________________________
 Observe student for evidence of seizure activity. If seizure is noted, follow
the
student’s Emergency Action Plan (EAP) and PPA, contact School Nurse
 Student has VNS?  Yes  No Trained adult will administer swipe
 Student has Klonopin?  Yes  No
Medication Assistant/Parent/Guardian/Licensed Nurse will administer
 Student has Diastat?  Yes  No or Student has Versed?  Yes  No
If yes, student will be accompanied by Licensed Nurse or Parent/Guardian
 Emergency Medication and/or VNS magnet should NOT be left in a backpack
on
the bus or with a Medication Assistant/Licensed Nurse who is not with
the student
If student IS authorized to self-carry emergency medication:
 Student will keep medication and/or VNS magnet on person at all times
 Trained adult will swipe VNS with magnet
 Klonopin/Clonazepam, if ordered by prescriber, will be administered by
Medication Assistant/Parent/Guardian/Licensed Nurse
 Diastat or Versed, if ordered by prescriber, will be administered by
Parent/Guardian or Licensed Nurse
Student is NOT authorized to self-carry emergency medication:
 Medication Assistant, Parent/Guardian or Nurse will accompany trip with
medication & orders to be kept on person
 Trained adult will swipe VNS with magnet
 Klonopin/Clonazepam, if ordered by prescriber, will be administered by
Medication Assistant/Parent/Guardian/Licensed Nurse
 Diastat or Versed, if ordered by prescriber, student will have ready access to
Parent/Guardian or Licensed Nurse for duration of the trip/event
 Call 911 immediately if emergency medication is given, student injury or
seizure >
5 min; then contact Parent/Guardian
EMERGENCY DRILLS AND SCHOOL CRISIS EVENTS
 School Nurse will secure medications & orders in accordance with school
safety plan
 In the event of building evacuation, School Nurse or Medication
Assistant will evacuate with medication(s)/magnet & orders

If authorized, student will keep medication(s)/magnet on person for
duration of
drill or crisis event

Student requires assistance during building evacuation?  YES  NO
If “YES”, describe: ________________________________________________

Other:
_________________________________________________________
Notes
revised 04/24/17
Nurse
Initial
Parent/Guardian
Initial
© Created by Huntsville City Schools
HS-P14-F8
revised 04/24/17
© Created by Huntsville City Schools