29818 S. North Pine Creek Road
Spangle, WA 99031
LIBERTY SCHOOL DISTRICT
Phone: (509) 624-4415
Fax: (509) 245-3530
BEE STING SENSITIVITY (No History of Anaphylaxis)
LICENSED HEALTHCARE PROVIDER ORDERS
EMERGENCY CARE PLAN / IHP / 504 PLAN (on reverse side)
Orders/care plan valid from August 1, ______ through July 31, ___________.
Student Name:
Birth Date:
Home Phone #:
Grade:
Allergies:
Date of Last Reaction:
Teacher:
Other Health Concerns:
Routine Medications:
Bus #:
Licensed Health Professional (LHP) Orders / Care Plan for Allergy
(Must be completed legibly by a licensed health professional)
If you know or suspect an exposure to ________________ (allergen/s), treat the reaction as follows:
1. Medication Doses
Antihistamine: __________________________cc/mg
Give: ________Teaspoons (12.5 mg/ml)
Tablets by mouth (25 mg.)
Repeat dose: Every _________ hours as needed.
Side Effects: ____________________________
2.
CALL SCHOOL NURSE (245-3211. ext. 2211) AND PARENT.
3.
PARENT IS TO TAKE STUDENT HOME FOR THE REMAINDER OF THE DAY.
SEVERITY OF SYMPTOMS CAN CHANGE QUICKLY.
Some Symptoms can be life-threatening! ACT FAST!
IF SYMPTOMS INCREASE –DON’T HESITATE TO CALL 911.
Anaphylaxis (severe allergic reaction) is an excessive reaction by the body to combat a foreign substance that has been
eaten, injected, inhaled or absorbed through the skin. It is an intense life-threatening emergency. Do not hesitate to CALL
911.
USUAL SYMPTOMS of an allergic reaction:
MOUTH--Itching, tingling, or swelling of the lips, tongue, or mouth
SKIN--Hives, itchy rash, and/or swelling about the face or extremities
THROAT--Sense of tightness in the throat, hoarseness and hacking cough
GUT--Nausea, stomach ache/abdominal cramps, vomiting and/or diarrhea
LUNG--Shortness of breath, repetitive coughing, and/or wheezing
HEART --“Thready” pulse, “passing out”, fainting, blueness, pale
GENERAL--Panic, sudden fatigue, chills, fear of impending doom
4. CALL 911 --IF SYMPTOMS INCREASE
Advise EMS that the student has been given Benadryl and has no epinephrine.
5. Notify parents and school nurse of change in condition, if they have not arrived already.
My signature below indicates that I have reviewed and approved the attached emergency care plan.
LHP Signature:
Print Name:
Start date:
End date (not to exceed current school year):
Date:
Telephone #:
Last day of school
Fax #:
Other:
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.
CALL 911 IMMEDIATELY!!! Begin rescue breathing
and CPR until relieved by EMS.
STUDENT EMERGENCY CONTACT INFORMATION
Student Name:
Birth Date:
Grade:
Parent/Guardian:
Parent/Guardian:
Other Emergency Contact:
Licensed Healthcare Provider Name:
Preferred Hospital:
Home Phone #:
Teacher:
Work Phone:
Work Phone:
Work Phone:
Phone:
Phone:
Bus #:
Cell Phone:
Cell Phone:
Cell Phone:
Fax:
PARENT/GUARDIAN CONSENT
My student may carry their own emergency medications. □ YES
□ NO
My signature indicates my involvement in and agreement with the plan and information provided. I understand:
 I must provide the Liberty School District with an Authorization for Administration of Medication at School Form for this
emergency medication signed by myself and my student’s Licensed Healthcare Provider.
 The Medication Authorization Form and emergency care plan must be renewed each school year.
 The School Nurse will work with me to prepare an Emergency Care Plan and/or Individualized Health Plan for my student
while at school. This plan will be reviewed and signed by both my student’s Licensed Healthcare Provider and myself.
 I am responsible for providing the prescribed emergency medication for my student in its original container with the
prescriptive label attached.
 The medication must be current and not past its expiration date.
 The School Nurse recommends that we provide back-up emergency medications in the school office. I understand that I do
not have to provide back-up medications for the school.
 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 persons as they board the bus or
arrive at school. I understand that my student athlete will also have to demonstrate to their coach that they are carrying their
emergency medications on their persons in order to participate in athletics.
 If my student receives any emergency medication, I may be required to pick them up from school and be responsible for
monitoring them for signs of further breathing difficulty or allergic reaction.
 If my student does 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 persons in order to participate in
athletics.
 The School Nurse will review with my student his/her knowledge of their health concern, the proper and prescribed timing for
using their emergency medications and the correct administration of the emergency medications as prescribed by their
healthcare provider.
 That the permission to possess and self-administer emergency medication may be revoked by the principal if it is determined
that my student is not safely and effectively self-administering their own medication.
I authorize the school registered nurse and/or nurse trained and delegated school staff to administer my student’s emergency
medications as needed and directed by their licensed healthcare provider.
I authorize the school registered nurse to communicate with my student’s healthcare provider about their medication or emergency
care plan.
Parent Signature: __________________________________________________ Date: ___________________________
I understand that in order to self carry my own rescue medications:
 I will need to keep my rescue medication in a secure place that will be easily accessible to me or to staff in the event of an
emergency.
 I will never share this prescribed rescue medication with any other staff or student.
Student Signature: _____________________________________________________
Date: _____________________________
School Nurse Signature: Sarah Beyersdorf, RN
Date: __________________________