Liberty School District
29818 S. North Pine Creek
Spangle, WA 99031
(509)245-3211
(509)245-3530 Fax
BEE STING SENSITIVITY (NO HISTORY OF ANAPHYLAXIS)
LICENSED HEALTHCARE PROVIDER ORDERS
EMERGENCY CARE PLAN / IHP / 504 PLAN
Orders/care plan valid from August 1, _____ through July 31, _____
Student Name:
Grade:
Sensitivities:
Date of Last Reaction:
Routine Medications:
Parent/Guardian:
Parent/Guardian:
Other Emergency Contact:
Preferred Hospital:
Birth Date:
Teacher:
Other Health Concerns:
Work Phone:
Work Phone:
Home Phone #:
Bus:
Cell Phone:
Cell Phone:
Phone:
Phone:
MEDICATION ORDERS
(Signed by a Licensed Healthcare Provider with Prescriptive Authority)
Antihistamine: _______________________
When to give: After ___________ exposure OR if student showing any
allergy symptoms.
Dose: __________________ mg. or ml. (12.5 mg/5 ml) Frequency: Every ______ hours.
My signature signifies that I have read and approved the Emergency Care Plan. Date: ____________________________
Licensed Healthcare Provider: _______________________________________ Phone Number: ____________________
Licensed Healthcare Provider Name: ___________________________________ Fax Number: ______________________
PARENT/GUARDIAN CONSENT
My signature indicates my involvement in and agreement with the plan and information provided. . I understand that if my
student receives their antihistamine, I will be required to pick them up from school and be responsible for monitoring them
for signs of further allergic reaction.
I understand that if I do not wish to provide back-up medications for the school, my student will be required to demonstrate to the bus
driver or school secretary (if driving or driven to school) that they have their medications on their person as they board the bus or arrive
at school. If they do not have their emergency medications with them, I understand that I will be notified to pick them up from school or
bring their emergency medications to school for them.
I understand that my student athlete will also have to demonstrate to their coach that they are carrying their emergency medications on
their person in order to participate in athletics.
Parent/Guardian Signature: _______________________________________________
Date: __________________________
School Nurse Signature: _________________________________________________
Date: __________________________
Updated: 11/11/2011
BEE STING SENSITIVITY EMERGENCY CARE PLAN / IHP / 504 PLAN
Student Name:
Grade:
Teacher:
Emergency medications are located in: □ ________ Medication Cupboard
□ The student’s backpack.
□ The student’s bus# ____
□ The student’s athletic coaches kit: __________________
□ The student locker. Locker #: ____________
Combination: __________________
Medications expire: Benadryl: ___________
Inhaler: _____________
Medical Problem: Sensitivity to _______________. No history of anaphylaxis.
IF YOU SEE THIS:
________’s normal symptoms are in bold type.
DO THIS:
- IF YOU KNOW OR SUSPECT _______________ HAS
Mental: “Feels scared or like “something bad is going to
BEEN STUNG, AN ADULT MUST ACCOMPANY ___ TO THE
happen”. Denial of symptoms. Changes in alertness.
OFFICE IMMEDIATELY. OR CALL THE OFFICE FOR HELP.
Skin: Hives, itchy rash or flushing. Itchy, teary or
NEVER SEND _____________ ANYWHERE ALONE!!!.
puffy eyes. Nasal congestion, itchiness, runny nose
- Notify the school nurse immediately at extension 2211.
or sneezing.
- Give emergency medications as listed below.
Mouth: Itching, tingling, or swelling of the lips, mouth,
tongue or throat.
***Throat: Itching and/or a sense of tightness in the
throat, hoarseness, hacking cough.
***Gut: Nausea, stomach cramps, vomiting and/or
diarrhea.
***LUNGS: Shortness of breath, repetitive coughing
and or wheezing. Chest tightness, hoarseness or
choking.
***HEART: Thready, faint or irregular pulse. Blue lips or
1.)
- Treat the sting:
a.) Remove the stinger with a fingernail or plastic card.
b.) Wash the sting site with soap and water.
c.) Circle the sting site with an ink pen. Apply Ban deodorant.
d.) Apply an ice pack to the sting site.
- A parent/guardian must pick up __________ to watch for
further signs of allergic reaction.
- __________ is to remain under direct adult supervision
until a parent/guardian arrives.
nailbeds. Rapid pulse and/or respirations. Increased
restlessness. Pale, cool or moist skin. Dizziness
or fainting. Loss of consciousness.
***The severity of symptoms can change quickly. - If __________ symptoms are increasing in severity OR
The starred symptoms can potentially progress involve more than one body system OR ____________
to a life-threatening situation. ***
complains of difficulty breathing - CALL 911.
- Notify the parent. DO NOT wait for the parent to arrive
before having EMS transport ________ to the hospital.
BREATHING OR HEARTBEAT STOPS.
Updated: 11/11/2011
CALL 911 IMMEDIATELY!!! Begin rescue breathing
and CPR until relieved by EMS.