Prevalent medical condition epilepsy



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PREVALENT MEDICAL CONDITION — EPILEPSY

Plan of Care (Sample)

STUDENT INFORMATION




Student Photo (optional)

Student Name _______________

Date Of Birth ______________

Ontario Ed. # ________________

Age _____________________

Grade _____________________

Teacher(s) ________________



EMERGENCY CONTACTS (LIST IN PRIORITY)

NAME

RELATIONSHIP

DAYTIME PHONE

ALTERNATE PHONE

1.










2.










3.






















Has an emergency rescue medication been prescribed?  Yes  No




If yes, attach the rescue medication plan, healthcare providers’ orders and authorization from the student’s parent(s)/guardian(s) for a trained person to administer the medication.




Note: Rescue medication training for the prescribed rescue medication and route of administration (e.g. buccal or intranasal) must be done in collaboration with a regulated healthcare professional.

KNOWN SEIZURE TRIGGERS

CHECK () ALL THOSE THAT APPLY

 Stress

Menstrual Cycle

 Inactivity

 Changes In Diet

 Lack Of Sleep

 Electronic Stimulation

(TV, Videos, Florescent Lights)



Illness

 Improper Medication Balance

 Change In Weather

 Other ________________________________________________

 Any Other Medical Condition or Allergy? ____________________________________________


_______________________________________________________________________________



DAILY/ROUTINE EPILEPSY MANAGEMENT

DESCRIPTION OF SEIZURE

(NON-CONVULSIVE)

ACTION:




(e.g. description of dietary therapy, risks to be mitigated, trigger avoidance.)











































DESCRIPTION OF SEIZURE (CONVULSIVE)

ACTION:











































SEIZURE MANAGEMENT

Note: It is possible for a student to have more than one seizure type.

Record information for each seizure type.



SEIZURE TYPE

ACTIONS TO TAKE DURING SEIZURE

(e.g. tonic-clonic, absence, simple partial, complex partial, atonic, myoclonic, infantile spasms)




Type: ________________________________











Description: ____________________________






Frequency of seizure activity: _______________________________________________________







_______________________________________________________________________________







Typical seizure duration: __________________________________________________________



BASIC FIRST AID: CARE AND COMFORT




First aid procedure(s): ____________________________________________________________




___________________________________________________________________




Does student need to leave classroom after a seizure?  Yes  No




If yes, describe process for returning student to classroom: _______________________________




_______________________________________________________________________________




BASIC SEIZURE FIRST AID

 Stay calm and track time and duration of seizure

 Keep student safe

 Do not restrain or interfere with student’s movements

 Do not put anything in student’s mouth

 Stay with student until fully conscious




FOR TONIC-CLONIC SEIZURE:

Protect student’s head

Keep airway open/watch breathing

Turn student on side




EMERGENCY PROCEDURES




Students with epilepsy will typically experience seizures as a result of their medical condition.




Call 9-1-1 when:

 Convulsive (tonic-clonic) seizure lasts longer than five (5) minutes.




 Student has repeated seizures without regaining consciousness.




 Student is injured or has diabetes.




 Student has a first-time seizure.




Student has breathing difficulties.




 Student has a seizure in water




Notify parent(s)/guardian(s) or emergency contact.









HEALTHCARE PROVIDER INFORMATION (OPTIONAL)

Healthcare provider may include: Physician, Nurse Practitioner, Registered Nurse, Pharmacist, Respiratory Therapist, Certified Respiratory Educator, or Certified Asthma Educator.
Healthcare Provider’s Name: _______________________________________________________




Profession/Role: ________________________________________________________________




Signature: ______________________________

Date: _________________________________




Special Instructions/Notes/Prescription Labels:







If medication is prescribed, please include dosage, frequency and method of administration, dates for which the authorization to administer applies, and possible side effects.

This information may remain on file if there are no changes to the student’s medical condition.






AUTHORIZATION/PLAN REVIEW

INDIVIDUALS WITH WHOM THIS PLAN OF CARE IS TO BE SHARED

1. _______________________


2. ________________________


3.____________________________












4.______________________

5.______________________

6.__________________________

Other Individuals To Be Contacted Regarding Plan Of Care:

Before-School Program

Yes  No

___________________________










After-School Program

 Yes  No

___________________________










School Bus Driver/Route # (If Applicable) _____________________________________________










Other:_________________________________________________________________________










This plan remains in effect for the 20___— 20___ school year without change and will be reviewed on or before: _________________________________. (It is the parent(s)/guardian(s) responsibility to notify the principal if there is a need to change the plan of care during the school year).




Parent(s)/Guardian(s): ___________________________________ Date: ____________________




Signature













Student: ______________________________________________ Date: ____________________




Signature













Principal: _____________________________________________ Date: ____________________




Signature







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