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Stcharles.k12.mo.us

City of St. Charles R-6 School District
400 N. Sixth St., St. Charles, MO 63301

Contact: _________________________ Fax: __________________ Student Name: ___________________________ D.O.B.: _________ School Yr: _________ Allergy with possible anaphylaxis reaction:________________________________________ Other know food or medication allergies: _________________________________________ Medications currently taking: __________________________________________________ Emergency Contact Information: ___________________________ Phone: _____________ Secondary Contact Information: ___________________________ Phone: _____________
MILD REACTION:
Symptoms:
Locate and follow student’s Individual Emergency Plan – Yes/No Give medication as prescribed
Give Benadryl Standing Order
Benadryl (diphenhydramine hydrochloride liquid or tablets) Preschool – 5th Grade: reaction without signs of anaphylaxis if anaphylaxis if parents cannot be reached. Call Parent Observe for additional symptoms Encourage student to be calm and relaxed

MODERATE REACTION:

Symptoms:
SEVERE REACTION:
Follow standing order for Epi-Pen®, Epi- Inability to speak more than a few words Provide support/comfort to student until
Directions for Administering Epi-Pen®

1. Pull off safety cap. (1) 2. Place tip on outer thigh at right angle to leg. (2) (For insect sting, inject leg opposite the sting.) 3. Press firmly into thigh. 4. Hold in place for 10 seconds. 5. Remove and massage area for 10 seconds.
Directions for Administering Twinject®

 Remove caps labeled 1 and 2, or red cap, green cap.  Place rounded tip against outer thigh, press down hard until needle penetrates.
SECOND DOSE ADMINISTRATION
If symptoms don’t improve after 10 minutes, administer second dose:
 Unscrew rounded tip, gray cap. Pull syringe from barrel by holding blue collar at  Slide yellow or orange collar off plunger.  Put needle into thigh through skin, push plunger down all the way, and remove.

Source: http://www.stcharles.k12.mo.us/coverdell/CHSMAllergicReactionPlan.pdf

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