Seizure Emergency Action Plan

Student Name:*

VALID FOR THE CURRENT SCHOOL YEAR*

Grade:*

Date of Birth:*

Parent/ Guardian Name:*

Parent/ Guardian Email:*

Parent/ Guardian Contact Number:*

Medical History:*

Date plan written:

_SEIZURE Information : THIS STUDENT IS BEING TREATED FOR A SEIZURE DISORDER. THE INFORMATION BELOW SHOULD ASSIST YOU IF A SEIZURE OCCURS DURING SCHOOL HOURS.

Seizure Type

Length:

Frequency:

Description:

Seizure triggers or warning signs:

Student response after seizure:

Standard First Aid	EMERGENCY FIRST AID
Stay calm Contact School Nurse at ext.711 Protect student from injury but do not restrain movements Help the student lie down and turn on one side if possible Loosen all tight clothing Do not put anything in the mouth Do not give medicines or fluids until the child is completely awake Stay with the student until he or she is fully alert and oriented Provide reassurance and support after the seizure episode CPR should not be given during a seizure Record the duration and describe the seizure on the epilepsy log Report the seizure to the appropriate person: parents, school nurse, and/or administrator	Emergency Medical Care if: Seizure lasts more than 5 minutes Another seizure begins soon after the first Student is injured or has diabetes The student stops breathing or has difficulty breathing after the seizure Student cannot be awakened after the seizure There are specific orders from the physician Start CPR for absent breathing or pulse The need for assistance is uncertain Student has a seizure in water

Standard First Aid

EMERGENCY FIRST AID

Stay calm
Contact School Nurse at ext.711
Protect student from injury but do not restrain movements
Help the student lie down and turn on one side if possible
Loosen all tight clothing
Do not put anything in the mouth
Do not give medicines or fluids until the child is completely awake
Stay with the student until he or she is fully alert and oriented
Provide reassurance and support after the seizure episode
CPR should not be given during a seizure
Record the duration and describe the seizure on the epilepsy log
Report the seizure to the appropriate person: parents, school nurse, and/or administrator

Emergency Medical Care if:

Seizure lasts more than 5 minutes
Another seizure begins soon after the first
Student is injured or has diabetes
The student stops breathing or has difficulty breathing after the seizure
Student cannot be awakened after the seizure
There are specific orders from the physician
Start CPR for absent breathing or pulse
The need for assistance is uncertain
Student has a seizure in water

TREATMENT PROTOCOL DURING SCHOOL HOURS :

(include daily and emergency medications)

Is Medication needed to control seizure?

Yes
No

List medication needed at school:

List

Daily medication	Dosage/Route/Time of Day Given	Common Side Effects and Special Instructions

Emergency/ Rescue Medication:

Dosage and Route:

Common Side Effects and Special Instructions

Special Considerations and Precautions(regarding school activities, sports, trips, etc.)

Describe any special considerations or precautions:

Signature

Date