Gainesville ISD Health Services

Seizure Emergency Treatment Plan

Student Name__________________________       Age_______   Weight__________

Treatment/Medication: ________________________mg: Route: ________ prn for:

_____ seizure > ____ minutes—OR for _____ seizures in _____ hours

_____ Use vagal nerve stimulator (VNS) magnet        other _________________

_____Call 911 immediately and administer rectal gel

                                            OR

Call 911 if:

_____ Seizure does not stop by itself or with VNS within _____ minutes

_____Seizure does not stop by itself within ______ minutes

_____Seizure does not stop within ____ minutes of giving diazepam rectal gel

_____Child does not start waking up within _____ minutes after seizure is over

(no diazepam rectal gel given)

_____Child does not start waking up within ____ minutes after seizure is over

 (after diazepam rectal gel is given)

Following a seizure:

_____Child should rest in the nurse’s office          _____Child may return to class

_____Parents should be notified immediately

_____Parents should receive a note/copy of the seizure record sent home with the child

Current Medications:______________________________________________________

Allergies________________________________________________________________

Type of seizures                   Description*             

Absence:                                Staring, eye blinking, loss of awareness, other___________

Simple partial                        Remains conscious, Involuntary rhythmic jerking/twitching on one side,

Seizures:                                distorted sense of smell, hearing , sight, other_____________       

Complex partial                     Confused, not fully responsive/unresponsive, may appear

Seizures:                                fearful, purposeless, repetitive movements, other______________

Generalized tonic-                Convulsions, stiffening, breathing may be shallow, lips or skin

clonic seizures:                     may have bluish color, unconsciousness, confusion, weariness, or belligerence when the seizure ends, other________________

Physician Signature                                                      Printed Name                             Date

Physician Address________________________________Phone_________________________

____________________________________________________________________________

Parent Signature                                           Date               Phone