EARLY INTERVENTION EARLY CHILDHOOD SPECIAL EDUCATION
MEDICAL PROTOCOLS
ALLERGIC REACTION PROTOCOL
Child’s Name:
Birthdate:
Parent/Guardian:
Home Phone:
Address:
Work Phone:
Additional Info:
Cell Phone:
Physician Treating Student for Allergies:
Work Phone:
Protocol Written By:
Date:
Specific Instructions:
If Stung by Insect:
After Ingesting:
After Exposure:
For Mild Systems such as:
a. Small localized rash or redness
b. Mild itching at area of contact
c. Eye irritation, watering, red eyes
d. Nasal drip or congestion
e. Intermittent sneezing
Do the following:
1.
Wash/rinse affected area thoroughly with running water.
2.
Monitor student for signs of anaphylaxis under direct observation for 60 minutes
3.
Advise parent of incident before returning student to class.
If symptoms increase or if any signs (listed below) are present:
a. Continuous sneezing, wheezing, or coughing
b. Shortness of breath or tightness of chest, difficulty in or
absence of breathing
c. Itching, with or without hives, raised red rash in any area of
the body
d. Difficulty swallowing
e. Swelling of eyes, lips, face, tongue, throat or elsewhere
f. Hoarseness
g. Sweating and anxiety
h. Nausea, abdominal pain, vomiting, or diarrhea
i. Dizziness and/or fainting
j. Involuntary bowel or bladder emptying
k. Sense of impending disaster or approaching death
l. Rapid or weak pulse
m. Skin flushing or extreme paleness
n. Burning sensation, especially face or chest
o. Blueness around lips, inside lips, eyelids
p. Loss of consciousness
Do the following:
1. If Epi-pen or other medication for allergic reaction has been provided by parent, give/use as directed
per attached Medication Authorization Form.
2. Call 911 immediately.
3. Begin CPR for absent breathing/pulse.
4. Notify Parent.
SIGNATURES:
Parent:
Teacher:
Date:
Date:
Service Coordinator :
Date:
EI/ECSE Nurse:
Date:
This authorization expires on ____________________ (not to exceed one year from the date of signature above).
(Month/Day/Year)
________________________________________________________________________________
For Office Use:
EI/ECSE Forms 10-2006
Copies To:
Parent
EI/ECSE Nurse
Transportation Office
Physician
EI/ECSE Office
Other ___________________