Food Allergy Health Care Plan Name: Parent: Home Phone: Emergency/Cell: DOB: Allergies: Medications:

Effective Date: School: Bus: yes no School Nurse: Doctor: Preferred Hospital:

Office # Office #

(Add personal data: i.e. onset, brief history, etc and change to regular font.) Anaphylaxis is a rare, life-threatening allergy to certain substances such as foods, bee stings, chemicals and medications. It occurs rapidly and can effect the entire body. It can close off the breathing passages; it can affect the skin (rash), it affects the heart and/or it can give stomach upset. If immediate treatment does not occur, it can be fatal. Exposure to this substance should be avoided, including skin contact, at all times! (____) wears a Medic Alert neck chain. (For the Nurse: Posting the picture, in the main office and in the lunchroom office (in a discreet place), of students with a history of anaphylaxis can be helpful. Nuts are a common cause for anaphylaxis Consider establishing a nut free zone at school. A nut free table at lunch is an easy accommodation. The table is reserved for any student that is eating a nut free lunch. The table must be washed with clean soapy water, separate from the other tables.) Problem: Breathing difficulty Goal: Maintain airway. Action: 1. (____) has a severe allergy to ________, which can be life threatening. 2. Symptoms of anaphylaxis include: Tingling sensation in the mouth Feelings of apprehension Swelling of the tongue and throat Difficulty breathing Hives Itching Vomiting and/or abdominal cramps Chest pain Diarrhea Drop in blood pressure Weakness or dizziness Wheezing Shallow respirations Loss of Consciousness. 3. If the above symptoms are noted: Do not hesitate to administer medication and call 911. a. If (____) presents with one of the above symptoms (i.e. hives or rash from skin contact) immediately give Benadryl as ordered by his/her health care provider. Wash the affected area with soap and water and call parents. Continue to monitor for progression of symptoms b. If two or more of the above symptoms are present immediately give Epi-Pen Jr. (Inject into lateral thigh and Benadryl as ordered by his/her health care provider. c. Call 911, and then call his/her parents. Problem: Epinephrine injection Goal: To understand what is given in the EpiPen or Twinjet Action: 1. Epinephrine is a hormone produced by all of us in the adrenal glands and is released in response to stress. An injection of epinephrine is a way to give a higher dose of something our bodies are already making. It is important to note that there is little downside to giving epinephrine if it is not needed. Delaying treatment can result in tragedy.

2. Epinephrine has three major actions that are important in the treatment of anaphylaxis. It constricts blood vessels and helps reduce the swelling caused by the allergic reactions. It helps to open the breathing passages and it helps prevent blood pressure from falling. 3. Epinephrine is very safe, but can cause minor side effects, including rapid heart beat, shakiness, headache, and restlessness. 4. Prepared to initiate CPR if breathing stops. Problem: School staff must be trained in how to give EpiPen or Twinjet injection. Goal: To understand how to give in the injection. Action: 1. The kit must be readily accessible and available at school or on field trips at all times. (____)’s medication will be kept at school in _____________. 2. Check expiration date every month to insure safety. 3. A minimum of three people must be trained in kit use. At school, _________, _______________, and ______________ are trained to give emergency injections. 4. Administration of EpiPen: 1. Take out of the plastic cover 2. Do not remove gray safety cap until ready to use. 3. Place black tip on the upper, outer thigh at right angle to leg. 4. Press hard into thigh until you hear the click. 5. Hold for 10 seconds against thigh. 6. Massage injection area for 10 seconds. 7. Discard injector properly. 8. Call 911 immediately. One person stays with (____) at all times. Notify parents 9. Prepare for a second injection as ordered. Repeat steps 1-7.

(OR) 5. Administration of Twinjet:

1. Pull off the green end cap labeled #1. You will now see a Gray cap. Never put your thumb, finger, or hand over the gray cap. 2. Pull off the red cap labeled #2. 3. Put the gray cap against the middle of the outer, upper thigh 4. Press down firmly and hold for 10 seconds against thigh. 5. Remove the twinjet- check the gray cap to make sure the needle is exposed. If you do not see the needle, repeat steps 3 and 4. 6. Call 911. Notify parents 7. Get ready for the second dose: unscrew and remove the gray cap (beware of the exposed needle). Then, holding the blue hub at the needle base. Pull the syringe from the barrel. Then slip the yellow orange or orange call or off the plunger. 8. If symptoms are the same or worse and Emergency medical personnel have not arrived, prepare a second dose. Inject the needle into the upper outer thigh and push the plunger in and remove the needle. 9. Discard injectors properly.

School Nurse Signature:


Trained Campus Staff Signature:___________________________________ _ Date:______________

Trained Campus Staff Signature:___________________________________ _ Date:______________

Trained Campus Staff Signature:___________________________________ _ Date:______________

For more information:


Anaphylactic  Reaction  Emergency  Steps     Observe  for  symptoms:   • • • • • • • •      

Apprehension  and  flushing   Sneezing,     Coughing,  wheezing,  or  shortness  of  breath,  hoarseness   Itching,  burning,  or  rash   Swelling  of  the  lips,  tongue  or  mouth,  tightness  in  the  throat   Pallor  or  bluish  color     Passing  out   Abdominal  pain  

When  in  doubt,  treat  for  the  reaction.  

Directions  for  use  of  the  EpiPen:   1.   PULL  OFF  THE  GRAY  SAFETY  CAP.   2.   PLACE  BLACK  TIP  ON  OUTER  THIGH.     3.   PUSH  EPIPEN  AUTO-­‐INJECTOR  AGAINST  THIGH  UNTIL  UNIT   4.   5.   6.   7.   8. 9.




Anaphylaxis is a life threatening immunologic

syndrome of acute onset, which has more systemic manifestations and often has an identifiable cause. Diagnosis: 1. 2.

History and physical exam Skin testing

Signs and Symptoms: 1. 2. 3. 4. 5. 6. 7.

Anxiety, flushing Rash and itching (skin and/or eyes) Nausea, vomiting, dizziness, sweating, headache Trouble breathing, sneezing, coughing, wheezing, runny nose Heart beat is irregular, chest pain Drop in blood pressure Abdominal pain

Management: 1. 2. 3. 4.

Clear and secure airway Rapidly assess level of consciousness Give Epi-Pen and/or Benedryl as ordered Position on back with legs elevated


Call 911 and alert parent

Prevention: 1. Avoidance

2. Epinephrine- when in doubt… treat!


TREE NUTS   Read  Labels  Carefully!     Common Names of Tree Nuts

Always Contains It  

Cashews   Nut  Meat,  Nut  Pieces  and  Nut  Oil   Pecans   Nut  Paste  (such  as  almond  paste)     Macadamia  nuts   Ganduja  (a  nut  mixture  in  some  chocolate)     Almonds   Pesto     Pistachios   Mandelonas   Brazil  nuts   Marzipan/Almond  Paste     Pine  nuts   Nan-­‐Gai  Nuts     Hazelnuts   Nougat   Walnuts   Pralines   Hickory  Nuts   Nut  Butters     Natural  Nut  Extract     Pinion   Artificial  Nuts     Common  Sources/Foods  Containing  Tree  Nuts:  Artificial   Nut  Meal   nuts  (peanuts  altered  to  look  and  taste  like  almonds,   Caponata   pecans  and  walnuts)            Other  Names  for  Tree  Nuts   Baked  goods  (cakes,  cereal  bars,  cookies,  doughnuts,   Anacardium  nuts   energy/granola  bars,  muffins,  pastries)   Mandelonas  (e.g.  peanuts  that  have  been  altered  to  Baking  mixes,  cereals,  crackers,  muesli   look  and  taste  like  tree  nuts)   Coffee  grinders     Marzipan  (almond  paste)   Dressings/gravies   Nu-­‐Nuts  ™  (e.g.  peanuts  that  have  been  altered  to   Chinese  food   look  and  taste  like  tree  nuts)   Gianduja  (chocolate  and  chopped  nuts  mixture  found  in     premium  or  imported  chocolate  and  ice  cream)   The  Following  Are  Nuts,  But  Not  Considered  “Tree   Ice  cream/frozen  desserts/frozen  yogurts/sundae   Nuts”:   toppings     Coconut                                  Lychee  Nuts   Natural  flavorings  and  extracts     Nutmeg                                  Shea  Nuts   Nut  butter       Water  Chestnuts     Nut-­‐flavored  coffee/liqueurs   Non-­‐Food  Sources  of  Tree  Nuts   Sauces  (barbeque,  pesto,  Worcestershire)   Hacky  sacks   Salads  (Waldorf  salad,  curried  chicken)   Bird  seed   Spreads  (almond  paste,  cheese,  chocolate  nut,  nougat,   Cosmetics,  hair  care  products,  lotions   Nutella)   Pet  food   Trail  mixes