MASCONOMET REGIONAL SCHOOLDISTRICT HEALTH SERVICES
20 ENDICOTT ROAD TOPSFIELD, MASSACHUSETTS 01983
(978)887-2323
HS Nurse ext. 6116 Fax # 978 887 7243 MS Nurse ext. 6125
Fax # 978 887 1991
SEIZURE CARE PLAN
Student
_____________________________________Date of Birth ___________Grade______
Seizure
Type________________________Date of diagnosis____________________ Date of last
seizure_______________________
Description of
seizure (what happens, duration,
frequency)_____________________________________________________________
Has student been
treated in the hospital for seizures in the past year? No Yes
When _____________________________
List conditions that
generally cause the seizure (e.g. noise, blinking lights)
_________________________________________________
How long after the
seizure before the student can return to his/her regular activities?
___________________________________________
Special needs,
activity restrictions/ adaptations or protective equipment needed at
school? No Yes (describe)
_______________
______________________________________________________________________________________________________________
ARE
MEDICATIONS NEEDED TO CONTROL THE SEIZURES? NO YES
(please list below the
medications needed)
|
MEDICATIONS |
AMOUNT TAKEN |
TIME OF DAY |
|
|
1 |
|
|
|
|
2. |
|
|
|
|
3. |
|
|
Circle the number of any of these medications to be taken at school.
PLEASE
ADVISE THE SCHOOL NURSE IMMEDIATELY OF CHANGES IN DOSE AND/OR TYPE OF
MEDICATION.
Basic
Seizure First Aid:
A Seizure is
generally considered an Emergency when:
Stay calm & track time
Keep child safe
Do not
restrain
Do not put
anything in mouth
Stay with child until fully
conscious
Record length of seizure
For tonic-clonic (grand mal) seizure:
Protect head
Keep airway open/watch breathing
Turn child on side
A convulsive (tonic-clonic) seizure
lasts longer than 5 minutes
Student has repeated seizures
without regaining consciousness
Student has a first time seizure
Student is injured or has
diabetes
Student has breathing
difficulties
Student has a seizure in water
IN ADDITION TO ABOVE, THE
USUAL PROCEDURE FOLLOWED AT SCHOOL INCLUDES:
1.
Provide for
student safety by removing nearby hazardous objects, loosening clothing at neck
and waist..
2.
Remove other
students from the immediate environment to give as much privacy as possible.
3.
Advise
parent/guardian of seizure
4.
Reorient the
student and guide student to safe locality
5.
Provide rest as
needed for student after the seizure
PLEASE
CONTINUE ON REVERSE
I give my permission for the school nurse to speak with my child's PCP regarding this diagnosis and to share with necessary school personnel information included in this document
No
Yes
Parent Signature ____________________________________________________Date
__________
Physician’s.Signature_________________________________________________Date_________
Student Signature ___________________________________________________Date __________
EMERGENCY CONTACTS:
Name:__________________________Relation:_____________Cell Phone_______________Home/work_______________
Name_______________________Relation____________Cell Phone____________Home/work____________
REMEMBER TO ADVISE THE SCHOOL IMMEDIATELY OF CHANGES IN
PHONE NUMBERS, ADDRESS,RESPONSIBLE
EMERGENCY CONTACT PERSON, DOCTOR, HOSPITAL PREFERENCES
Masconomet has a policy regarding taking
medications at school. Please call the
school nurse for direction
Tests and activity
restrictions occurring during school hours require written direction from your
child’s doctor.
FOR RN USE ONLY Reviewed
on : ___________________
procedure Seizures (950) medication
procedure
________________________________________ ____________________________________________________________________________________________ Name
Date Trained __________________________________________________________________________
Nursing Dx Plan
Stable history (899) P: Standard seizure
Potential complication P: Standard school 
High risk for _______________P:
Individual SHMP
Delegated or 
Assigned Caregiver(s) R.N. Signature