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Anaphylaxis

Respiratory

 

This resource provides current and comprehensive non-emergency health care planning information for school health nurses. Related procedures, instructional videos and downloadable skills checklists can be searched by selecting the [More Information] button at the bottom of this web page.

Overview

“Anaphylaxis is an acute clinical syndrome resulting from the interaction of an allergen and a patient who is hypersensitive. This antigen-antibody (immunoglobulin E [IgE]) reaction stimulates the release of chemical substances, primarily histamine, from mast cells” (Duffy, 2024, p.757). Severe allergic reactions are frequently immediate, life threatening, and involve multiple systems including cardiovascular, respiratory, gastrointestinal, and integumentary (Duffy 2024, p. 757). A second anaphylactic reaction, known as a biphasic reaction, can occur as long as 12 hours after the initial reaction so prompt treatment with epinephrine and follow up in an emergency department is very important (American College of Allergy, Asthma, and Immunology, 2018; Gereige, Jastaniah, et al., 2022).

The most common causes of anaphylaxis include foods, insect stings, medications and latex. Exposure to the antigen can be through ingestion, inhalation, skin contact, or injection (Duffy, 2024). Eight foods or food groups account for most serious allergic reactions in the United States: milk, eggs, fish, crustacean shellfish, wheat, soy, peanuts, and tree nuts (Division of Population Health, National Center for Chronic Disease Prevention and Health Promotion, 2022). 

Warning signs of an anaphylaxis reaction typically affect more than one part of the body and may include:

  • Red rash, with hives/welts, that is usually itchy (It is possible to have a severe allergic reaction without skin symptoms.)
  • Swollen throat or swollen areas of the body (It is possible to have a severe allergic reaction without skin symptoms.)
  • Wheezing
  • Dizziness
  • Passing out
  • Low blood pressure
  • Rapid heartbeat
  • Chest tightness
  • Trouble breathing, cough
  • Hoarse voice
  • Trouble swallowing
  • Nausea
  • Vomiting
  • Diarrhea
  • Stomach cramping
  • Pale or red color to the face and body
  • Feeling of impending doom

(American Academy of Allergy, Asthma & Immunology, 2023; American College of Allergy, Asthma, & Immunology, 2018).

Children who are experiencing an anaphylaxis reaction may describe their symptoms in the following ways:

  • “This food is too spicy.”
  • “My tongue [or mouth] is hot [or burning, tingling, itching].”
  • “It feels like something’s poking my tongue.”
  • “It [my tongue] feels like there is hair on it.”
  • “My tongue feels full [or heavy or funny].”
  • “There’s something stuck in my throat.”
  • “My neck hurts/ feels sore.”
  • “It feels like a bump is on the back of my tongue [throat].”
  • “My lips feel tight.”
  • “It feels like there are bugs in there.” (to describe itchy ears)
  • “My eyes are burning [or itchy].”
  • “My skin feels itchy.”
  • “My stomach [or tummy] hurts.”
  • “My chest is tight.”
  • “Something is wrong” or “Something bad is happening.”

(Food Allergy Research and Education, 2019)

Children who have allergies or asthma and have a family history of anaphylaxis, have a higher risk of anaphylaxis. Additionally, if the child has experienced anaphylaxis their risk of having another anaphylactic reaction is increased (American Academy of Allergy, Asthma & Immunology, 2023).

Delegation

Delegation of epinephrine administration is a common practice in the school setting. The National Association of School Nurses’ (2018) training document  Food Allergies and Anaphylaxis Sample Checklist for Training School Personnel indicates that “school personnel that have contact with students with food allergies or risk for anaphylaxis” (p. 2) should be trained on how to administer an epinephrine auto-injector. In order to determine if delegation of epinephrine auto-injector administration is safe and appropriate, the school nurse should answer the following delegation questions for each individual student diagnosed with anaphylaxis.


Questions to Ask to Inform Safe Delegation: The delegation questions below are based on the American Nurses Association’s Decision Tree for Delegation by Registered Nurses (ANA, 2012) and the National Association of School Nurses’ Emergency Medication Administration Delegation Decision Tree (NASN, 2020a).


1. Has the school nurse performed an initial assessment of the student to determine their needs?
The school nurse should not delegate the procedure to an Unlicensed Assistive Personnel (UAP) until they have completed the initial assessment.

2. Does school district policy, the school nurse’s job description, and the UAP’s job description allow the delegation of administering epinephrine auto-injector?
Although the Missouri Nurse Practice Act and Missouri Statute 167.630.  Epinephrine prefilled auto syringes, school nurse authorized to maintain adequate supply — administration authorized, when allows for registered nurses to delegate administration of epinephrine auto-injectors to school staff, the school nurse should ensure that the district does not have policies that prohibit or limit the school nurse’s ability to delegate. Additionally, the school nurse should review their own and the UAP’s job description to confirm that it is appropriate to delegate this procedure.

3. Is the school nurse competent to perform this procedure or does the school nurse need to acquire some knowledge or skills to be competent in this procedure?
If the school nurse does not have the knowledge or skills or does not feel comfortable performing this procedure, they should not delegate this procedure to a UAP. The school nurse must first acquire the necessary knowledge and skill to perform this procedure competently before they can delegate it to someone else.

4. Does the student have any other health conditions that make their overall health status unstable?
The student’s health condition should be stable so that when the epinephrine administration is completed by following a set procedure or protocol the student is not at undue risk.

5. Are the results of the epinephrine administration reasonably predictable?
If the results of the epinephrine administration are not predictable then this procedure should not be delegated. 

6. Does the UAP have the appropriate knowledge, skills, abilities, and willingness to perform the procedure?
All these factors need to be considered. Although a UAP may be competent to perform the procedure they may not be willing to do so and in that situation another UAP should be identified and trained. The registered nurse must retain responsibility for the procedure until training is complete.

7. Is there a procedure and/or protocol in place for this procedure?
A delegated nursing procedure must have an established sequence of steps that the UAP can follow. These steps should have a predictable outcome. The steps should be outlined in a written procedure or protocol. If the written procedure/protocol has not been developed, the school nurse should retain responsibility for the procedure until the procedure/protocol is in place. (The National Association of School Nurses have developed an Allergic Reaction Algorithm for Management of Medical Emergencies that can be used as a template).NASN Algorithm-Allergic-Reaction

8. Is the school nurse able to provide supervision to the UAP (direct or indirect depending on the situation)?
If the school nurse is not able to provide supervision, then the procedure should not be delegated. The school nurse will need to assess the situation to determine if direct or indirect supervision is required. The school nurse may also need to reassess the situation if the environment changes, for example, if the procedure is going to be performed during a time that the school nurse is not contracted to provide nursing services (i.e., over the weekend, during the summer, or if the school nurse is part-time).

9. Is the student ready to assume some responsibility for the procedure?
The school nurse should resume responsibility for the procedure since the school nurse is the only one who can initiate teaching. The school nurse would also want to observe the student performing the procedure to ensure that the student is competent. Once the school nurse has determined that the student is competent and can safely perform the procedure independently, they can delegate the supervision of the student to a UAP. If at a future date the school nurse is needed to teach the student additional skills, the school nurse would again need to resume responsibility for the procedure until the time in which the school nurse determined the student to be competent.

Delegation Decision Tree and Delegation Checklist (NASN)

The Decision to Delegate:

There may be times when the school nurse and school administrator have conflicting opinions on the delegation of a procedure to a UAP. The school nurse may feel that delegation is not appropriate or the administrator may want the school nurse to delegate a procedure to an UAP that the school nurse feels is not competent. In these situations the school nurse may need to educate the administrator that the school nurse has a professional and legal responsibility to determine if delegation of a nursing procedure is appropriate and safe (ANA, 2012).

A resource developed by the National Association of School Nurses entitled, Fact Sheet for School Administrators, Families, and School Personnel: Nursing Delegation Requires the School Nurse may assist the school nurse in communicating with the school administration. For continued learning see Navigating Delegation in the School Setting (PDF)

School Environment

Proper management of the school environment plays a critical role in the mitigation and prevention of anaphylaxis. The school environment includes the people within the school (i.e., students, staff, and visitors), the physical environment (i.e., classroom, cafeteria, and playground) and the resources available within the school (i.e., epinephrine auto-injectors, school staff who are educated and trained to respond to anaphylaxis emergencies). The school community is also impacted by school policies.

Physical Environment:

“Food Allergen Aware” vs “Food Allergen Free” spaces:  Although some may consider banning certain foods from the school (i.e. peanuts), it is not recommended. The Centers for Disease Control and Prevention (CDC) states, “such an option cannot guarantee a totally safe environment because there is no reasonable or fail-safe way to prevent an allergen from inadvertently entering into a building” (2013, p. 39). It is recommended to create Allergen Aware space instead (NASN, 2023e). Allergen Aware practices include creating food-free zones and posting signs to inform others; developing and enforcing classroom food guidelines; implementing food marked areas with clear boundaries and a description of food allergies; developing and enforcing a no food sharing policy; creating food-free zones in the cafeteria with signs posted; designating nut-free cafeteria tables; and educating school staff and students (Northern Health, 2022).

Access to Epinephrine: A prompt and coordinated response to an anaphylaxis reaction is critical. School staff who have regular interactions with a student with known anaphylaxis should know where the student’s epinephrine is located. If the student self-possesses their epinephrine, the student should communicate the location of their epinephrine with school staff and the school nurse. If the school has a stock epinephrine program, the medication should be stored in a location that is easily accessible (CDC, 2013)

Stock Epinephrine: The School Access to Emergency Epinephrine Act (2013) was signed into law, to encourage states to adopt laws requiring K-12 schools to have access to undesignated epinephrine auto-injector or stock (non-student specific) epinephrine auto-injector. Missouri statute 167.630.  Epinephrine prefilled auto syringes, school nurse authorized to maintain adequate supply — administration authorized, when allows for stock epinephrine. Considering that 25% of epinephrine administration in the school setting is for a child who has not been diagnosed with anaphylaxis (Davis & Kelso, 2018) stock epinephrine programs are a key component to emergency preparedness.

When planning for a stock epinephrine program the school nurse should consider the following:

  • Acquisition of an order for stock epinephrine from the school’s medical advisor.
  • Funding source to cover the cost of initial supply of epinephrine auto-injectors and other needed supplies (i.e., storage equipment) and subsequent doses of epinephrine, as needed.
  • Acquisition of epinephrine auto-injectors in both doses (0.15 mg and 0.30 mg) to maintain adequate stock at each of the school buildings within the district.
  • Development of a process to systematically check the expiration date(s) of the stock epinephrine.
  • Development of an epinephrine policy, procedure, and protocol.
  • Sample protocol developed by NASN (https://tinyurl.com/4ynb7ayf)
  • Training of all school staff on anaphylaxis, risk reduction, and response to anaphylactic episodes.
  • Training of designated staff who will be responsible for administering epinephrine in response to an anaphylactic reaction.
  • Designation of location of stock epinephrine. Location of stock epinephrine should be easily identified and accessible. Depending on the size of the building, multiple stock epinephrine locations may be needed. 
  • Determination if stock epinephrine will be available for before and after school events.
  • Determination of whether other groups using the school building will have access to stock epinephrine (community groups not associated with the school).

(Moritz & Schoessler, 2018; NASN, 2023a).

Classroom Management: Teachers and other school staff who have regular interactions with a student with anaphylaxis should be educated and trained to respond to an anaphylaxis emergency. They should also know where the student’s epinephrine is stored and have easy access to the medication. To help reduce the risk of anaphylaxis, teachers and other classroom staff may want to consider implementing the following practices:

  • Handwashing:
    • Promote hand washing practices following eating to prevent cross-contact using recommended procedures of soap and water or hand wipes when soap and water are not available. Hand sanitizers are not effective for removing food allergens or dirt.
  • Food sharing:
    • Prohibit meal/snack swapping, utensil swapping among students, and eating on school transportation.
  • Allergen-aware zones:
    • Consider options for allergen-aware zones such as the classroom, lunch tables, or cafeteria zone to decrease exposure to allergens, including latex. Consider plans to ensure that common areas (such as libraries, music, and art rooms) are also allergen-aware zones. No student should be required to sit at a designated table or area.
  • Celebrations/special events:
    • Plan for celebrations (birthdays, school parties, holidays, and other school events) that may include alternatives to food for celebrations, provisions for allergy-free foods for celebrations, etc.
  • Science projects/other kits:
    • Evaluate the safety of these supplies for those with food, latex, and insect allergies.
  • Emergency preparedness:
    • Plan for fire drills, lockdowns, or shelter in place, which may include considerations for access to medications or allergy-free foods, etc.

(Missouri Department of Health and Senior Services, 2014, p. 15)

Education of School Staff:

All school staff should be educated on the basics of allergies and anaphylaxis. The National Association of School Nurses (NASN) recommends a tiered approach to school staff education.

  • Level 1: Provided to all school staff would include:
    • Basic information about allergies and anaphylaxis
    • How to respond to an allergy-related emergency
  • Level 2: Provided to school staff who have regular contact with the student
    • More in depth discussion of the information provided in Level 1 training
    • Information on allergens
    • School wide response to allergen exposure or symptoms of anaphylaxis
    • Symptoms of anaphylaxis
    • Administration of epinephrine with a return demonstration (NASN, 2018).

See NASN’s Food Allergies and Anaphylaxis Sample Checklist for Training School Personnel and the Emergency Preparedness section for more information.

In addition to the education and training outlined in the NASN Food Allergies and Anaphylaxis Sample Checklist the Missouri Department of Health and Senior Services (2014) also recommends that the school nurse should consider providing school staff with information on the following:

  • Avoidance strategies for the identified allergen(s).
  • Recognition of symptoms and what to do if the student is exposed to the allergen or exposure is suspected.
  • Instruction on the administration of epinephrine.
  • Instruction on the administration of oral medication as ordered. The student’s health care plan may also order an oral antihistamine to be administered.
  • School notification procedures for calling 911 or Emergency Medical Services (EMS), parents, school nurse, and school administration.
  • Pertinent blood-borne pathogen information training with emphasis on safe handling of contaminated sharps.
  • Proper documentation of the incident, including medications administered, the amount of medication administered, time, and by whom.
  • Confidentiality of health care information.
  • Identification of harassment or teasing situations that may result in a student being exposed to the allergen. All students should be taught bullying, harassing, or intimidating will not be tolerated. It is expected that students found to be subjecting a student with a life-threatening food allergy to such behavior will be disciplined according to district policies.
  • Retraining annually, if the student’s condition changes, or if there is a change in staff assigned to implement the Emergency Action Plan.
  • At least annual practice of Emergency Action Plan procedures.

School Policy:

Missouri statute 167.208. Allergy prevention and response policy required, contents — model policy authorized requires schools to have policy on allergy prevention and response, with priority given to addressing potentially deadly food-borne allergies.  The policy shall contain, but shall not be limited to, the following elements:

  • Distinguishing between building-wide, classroom, and individual approaches to allergy prevention and management;
  • Providing an age-appropriate response to building-level and classroom-level allergy education and prevention;
  • Describing the role of both certificated and noncertificated school staff in determining how to manage an allergy problem, whether it is through a plan prepared for a student under Section 504 of the Rehabilitation Act of 1973 for a student with an allergy that has been determined to be a disability, an individualized health plan for a student who has allergies that are not disabling, or other allergy management plans;
  • Describing the role of other students and parents in cooperating to prevent and mitigate allergies;
  • Addressing confidentiality issues involved with sharing medical information, including specifying when parental permission is required to make medical information available;
  • Coordinating with the school health advisory council, local health authorities, and other appropriate entities to ensure efficient promulgation of accurate information and to ensure that existing school safety and environmental policies do not conflict. 

Given the requirement for schools in Missouri to have this policy, it would be important for the school nurse to understand their role and responsibility in the implementation and periodic review of the policy. Click on the link to access a sample policy,  Student Allergy Prevention and Response, from Missouri Department of Elementary and Secondary Education.

See the National Association of School Nurses Food Allergies and Anaphylaxis Sample Checklist for Training School Personnel for more information.

Students

An important first step when caring for a student who is diagnosed with an anaphylaxis allergy would be to complete a health history and physical assessment, preferably with the student and their parents present.

Health History Questions:

  • Medical conditions
  • Does the student have a diagnosis of asthma?
  • Medications
  • Allergies
  • Description of past allergic reactions including:
    • Triggers
    • Signs/symptoms the child experienced
    • Child’s verbal description of the signs and symptoms or how they felt during the anaphylactic event
    • How quickly did signs and symptoms appear?
  • How many times has the student had an anaphylactic reaction?
  • When was the last anaphylactic reaction?
  • What medication was used to treat the anaphylactic reaction?
  • Has the student been seen in the emergency department due to anaphylactic reaction?
  • Previous hospitalizations
  • Does the student require meal modifications or substitutions?
  • Insurance coverage
  • Health care provider(s) name and contact information
  • Preferred hospital, if applicable

(Missouri Department of Health and Senior Services Bureau of Community Health and Wellness, 2021; National Association of School Nurses, n.d.; National Association of School Nurses, 2023d; St. Louis Children’s Hospital, Food Allergy Management and Education Program, 2017-2022a;)

Assessment Questions: The school nurse may want to consider asking the student and their parents/guardians the following additional questions:

  1. Does the student have an Emergency Action Plan (EAP)?
  2. Has the student been educated and trained to administer their own epinephrine auto-injector?
  3. Has the student ever administered their own epinephrine auto-injector?
  4. Does the student self-carry their epinephrine auto-injector?
  5. How does this health condition impact the student’s daily life?
  6. Does the student know what foods or other triggers (i.e. insects) to avoid?
  7. Does the student read and understand food labels?
  8. Does the student have a history of telling an adult immediately after an exposure?
  9. Does the student wear a medical alert bracelet, necklace, watchband?
  10. Has the student shared information about their anaphylaxis allergy with their peers?
  11. Does the student or parents have any concerns about the student’s health condition?
  12. What challenges does the student face in managing their health condition?
  13. Do you feel the student has been sufficiently supported by school staff in managing their health condition?
  14. Does the student have a 504 Plan or Individualized Education Program (IEP)?
  15. Would the student benefit from evaluations or assessments in any of the following areas: physical therapy, occupational therapy, speech and language therapy, assistive technology, adapted physical education, functional behavior, psychology, hearing and vision?
  16. Would the student benefit from additional academic support and/or modified education (i.e.., copies of notes, extra time, reduced workload, simplified instructions, alternative formats for presentation of material, 504/IEP)?
  17. Does the student have an Individualized Health Care Plan (IHCP)?
  18. Is there a need for a specific plan for this student’s individual needs if there is a crisis in the building?
  19. How is the student transported to and from school?
  20. Does the student attend before or after school care?
  21. Does the student participate in school-sponsored clubs or athletics?

(Missouri Department of Health and Senior Services Bureau of Community Health and Wellness, 2021; National Association of School Nurses, n.d.; National Association of School Nurses, 2023d).

Transition Planning:

The school nurse should assess the student’s current and desired level of independence to determine what goals should be established for the student. Additionally, the school nurse should discuss with the student and family what steps have been initiated related to transition planning. The school nurse should consider including goals related to self-management and decision-making skills in the student’s Individualized Health Care Plan (IHCP) (NASN, 2019b) and consider how those goals can be expanded upon each year to support independence, if appropriate.

For a student with anaphylactic allergies, an important part of transition planning would be learning how to self-administer epinephrine. The American Academy of Allergy, Asthma, and Immunology (2020) recommends that the process should begin early in elementary school (kindergarten/first grade) with education. They recommend that by middle school the student should be able to self-possess and self-administer epinephrine. They recommend that children learn to self-carry and self-administer epinephrine before reaching their teens since multiple studies show higher risk of non-compliance and greater risk-taking behaviors which could lead to more severe and fatal anaphylaxis. The school nurse should utilize the student’s Individualized Health Care Plan (IHCP) to develop student and family goals related to self-possession and self-administration of epinephrine. (See the Documentation section for more information in IHCPs).  Got Transition has developed Transition Readiness Assessment for Youth and a Transition Readiness Assessment for Parents/Caregivers

Transportation:

It is important for the school nurse to determine how the student is transported to and from school. If the student is transported on the school bus the school nurse may be required to educate school bus drivers on anaphylaxis and train them on how to administer epinephrine. The school nurse should confer with the school administrator to determine who is responsible to provide the training as school bus drivers who are employed by an outside agency may receive their training through their employer.

Communication

Anaphylaxis risk reduction and response requires effective communication with and between multiple stakeholders. At the center are the student and their family. School personnel, such as the school nurse, need to communicate with the family to ensure all the necessary information and documents are available at school, including health care providers order(s), emergency plans, and contact information. The school nurse also needs to ensure that they are communicating with school staff to provide the necessary education and training. The school staff need to make certain that they are communicating with students and their families and educating them on the school and classroom requirements related to allergen-reduction practices (i.e., allergen aware spaces, limiting food in the classroom, no food sharing policies, etc.). School leaders also need to establish effective methods of communicating during an emergency, paying special attention to times when staff are outside of the school building (i.e., during recess) and when students are in transport (i.e., on the bus coming to and from school).

The school nurse needs to discuss with the student and their family the best way(s) to communicate with them. Does the parents/guardian have a preference (i.e., email, text, telephone call)? Do the parents prefer to have the communications sent to both parents or is there a parent who manages the communication with the school nurse?

The school nurse may want to consider having the parents/guardians complete a Health Insurance Portability and Accountability Act (HIPAA) compliant medical release form to facilitate communication with the student’s health care team. Although HIPAA does not require parental consent to allow the school nurse to discuss the student’s treatment plan, such as medications and nursing procedures, with the student’s health care provider, having a signed consent form would undoubtedly make the process go smoother for all involved parties (U.S. Department of Health and Human Services & U.S. Department of Education, 2008).

FERPA_HIPAA_Consent_Sample

Medication

Epinephrine:
“Epinephrine is the only medication that can reverse the symptoms of anaphylaxis. Epinephrine is a safe and relatively harmless drug. When in doubt, use it! The risks of anaphylaxis outweigh any risks from giving the medication” (Food Allergy Research & Education, 2023a). Some children may have an order from a health care provider for antihistamines (diphenhydramine or Benadryl) but antihistamines are not first line treatment for anaphylaxis. The American Academy of Allergy, Asthma, and Immunology (2021) states, “Epinephrine saves lives, antihistamines only treat hives” (p.1). It is recommended that two doses of epinephrine be carried at all times since a severe allergic reaction may require two doses or a student may require a second dose if a biphasic reaction occurs (Davis & Kelso, 2018).

Health Care Provider Order:

Frequently, the health care provider’s order for emergency epinephrine administration will be included in the student’s Emergency Action Plan (see the Documentation and Emergency Preparedness sections for more information on Emergency Action Plans). If the student does not have an Emergency Action Plan, at a minimum, the following information should be included in the health care provider’s order for epinephrine administration:

  • Name of the student
  • Date of birth
  • Name of medication
  • Dose
  • Route
  • Time of administration
  • Reason for administration
    • The reasons for administration are typically listed as the symptoms of anaphylaxis

Asthma and Anaphylaxis: Some students with anaphylaxis allergies may also have asthma. For students with dual diagnoses, a second Emergency Action Plan (Asthma Action Plan) for the student’s asthma management may be necessary. More information on the management of asthma in the school setting can be found on Asthma or in the downloadable, In-depth Asthma 27 page pdf document.

 Student Possession and Self-Administration of Epinephrine:

Statute 167.627 RSMo. Possession and self-administration of medication in school — requirements allows for a student diagnosed with anaphylaxis to possess and self-administer their epinephrine if the following conditions are present:

  • A licensed physician prescribed or ordered such medication for use by the pupil and instructed such pupil in the correct and responsible use of such medication.
  • The pupil has demonstrated to the pupil’s licensed physician or the licensed physician’s designee, and the school nurse, if available, the skill level necessary to use the medication and any device necessary to administer such medication prescribed or ordered.
  • The pupil’s physician has approved and signed a written treatment plan for managing the pupil’s chronic health condition, including asthma or anaphylaxis episodes and for medication for use by the pupil.  Such plan shall include a statement that the pupil is capable of self-administering the medication under the treatment plan;
  • The pupil’s parent or guardian has completed and submitted to the school any written documentation required by the school, including the physician approved and signed treatment plan and the liability statement required (see next bullet point);
  • The pupil’s parent or guardian has signed a statement acknowledging that the school district and its employees or agents shall incur no liability as a result of any injury arising from the self-administration of medication by the pupil or the administration of such medication by school staff.  Such statement shall not be construed to release the school district and its employees or agents from liability for negligence.

 

The statute goes on to state that an authorization granted shall:

  • Permit such pupil to possess and self-administer such pupil’s medication while in school, at a school-sponsored activity, and in transit to or from school or school-sponsored activity; and
  • Be effective only for the same school and school year for which it is granted.  Such authorization shall be renewed by the pupil’s parent or guardian each subsequent school year in accordance with this section.
  • Any current duplicate prescription medication, if provided by a pupil’s parent or guardian or by the school, shall be kept at a pupil’s school in a location at which the pupil or school staff has immediate access in the event of an asthma or anaphylaxis emergency.
  • The physician has approved and signed a written treatment plan and the liability statement signed by the parent/guardian shall be kept on file at the pupil’s school in a location easily accessible in the event of an emergency.

 

Sample documents: Permission for Student to Self-Carry and Self-Administer
Epinephrine (Epi-Self-Carry PDF)from Parkway Schools  and a fillable template Authorization for Students to Self-Carry from
St. Louis Children’s, Food Allergy Management and Education Program.

 The National Association of School Nurses has developed a Contract for Student Self-Carry and Self-Administration of Medication that could be used to document the school nurse’s assessment and planning with the student. The Colorado
Department of Education has developed an Asthma/Allergy Self-Carry Medication Contract.

Field Trips

Many schools may have implemented policies and procedures in an effort to reduce a student’s potential exposure to anaphylactic triggers in the school building, but these policies and procedures may be more difficult to implement on field trips given the unpredictability and lack of control over the environment. School staff have less control over the environment especially if the field trip is occurring outside. Considerable planning for possible emergencies should be undertaken. In addition, school staff should also review potential exposure to anaphylactic triggers and brainstorm prevention strategies.

It is important to note that the Section 504 of the Rehabilitation Act does not allow for a student with a disability to be excluded from a field trip due to their disability.

The school nurse & school staff should consider the following when planning for a field trip:

  1. Confirm that students on the field trip who have diagnosed anaphylaxis have all the necessary items for the field trip including:
    • Health care provider order/Emergency Action Plan
    • Epinephrine auto-injector(s)
    • Emergency Contact Information
  2. Ensure that the Emergency Action Plan is up-to-date and reviewed to determine if any revisions are needed due to the field trip.
  3. Plan to have emergency plans stored with the medication during the field trip. Consider what steps will need to be taken to ensure health plans remain confidential.
  4. Determine where emergency medication will be stored keeping in mind temperature stability, accessibility, and safety.
    • Emergency medication should not be left unattended on the school bus or with a school staff/volunteer who is not with the student.
  5. Identify which students will be allowed to self-carry their emergency medication. Ensure that proper education, training, competency, and documentation has been completed.
  6. Determine how medications administered on the field trip will be documented.
  7. Develop a plan to obtain additional emergency medication, if needed.
  8. Determine locations of emergency departments and hospitals along the route for the field trip and in the vicinity of the final field trip destination.
  9. Determine if any additional staff are needed on the field trip to meet the health care needs of the students.
  10. Identify whether school staff who will be accompanying students on the field trip have the necessary training, education, and competence to perform any emergency procedures such as epinephrine administration.
  11. If a trip includes an overnight stay at a hotel, request rooms with kitchens, refrigerators, and microwaves so food allergic students can cook their own meals.
  12. Call all destination locations, including travel stops, restaurants, and hotels, ahead of time to ensure accommodations are available for student(s) with food allergies.
  13. If a field trip will be outdoors or in locations with potential exposure to insect/animal allergen, plan ahead to reduce potential exposure.
  14. Be sure to store lunches of students with food allergies separately to minimize cross contamination.
  15. Consider that there may be areas where cellphone reception is limited or not available and plan accordingly.
  16. If the field trip will be occurring out of the state:
    • Review the states’ Nurse Practice Acts to confirm that the administration of epinephrine via auto-injector can be delegated to an UAP in that state.
    • Determine if the states traveled through or visited are a part of the Nurse Licensure Compact.
  17. If the field trip will be occurring out of the country the school nurse should discuss with school administration any applicable laws to determine what additional steps may be needed. In addition, the U.S. Embassy can provide information on points of contact for destination countries.

    (Erwin, Clark, & Mercer, 2014; NASN, 2019a; NASN, 2020b; NASN, 2021; Wisconsin Department of Public Instruction, 2019)

The Field Trip planning checklist above was developed based on the National Association of School Nurses’ Emergency Medication Toolkit (NASN, 2020).

Resources for field trip planning: NASN Resource: Field Trip Preparation Checklist

St. Louis Children’s Hospital, Food Allergy Management and Education Program has developed a Field Trip Risk Assessment form.

Documentation

The medical management of anaphylaxis allergies in the school setting will require the school nurse to acquire and complete numerous forms of documentation.

Health Care Provider Order: Frequently the health care provider’s order for epinephrine administration is written as an Emergency Action Plan (EAP). If the student does not have an EAP then the school nurse will need a health care provider’s order for the medication administration. See the Medication section for more information.

Emergency Action Plan: In addition to documenting an assessment and health history, and each time medication is administered, there will be additional health records and documentation requirements for a student with an anaphylactic allergy. One of the most important documents is the EAP. Many times a student with a known anaphylactic allergy will have an EAP written (or the template completed) by their health care provider. A few organizations have developed EAP templates including the American Academy of Allergy, Asthma, and Immunology (AAAAI), the American Academy of Pediatrics (AAP), Food Allergy Research and Education (FAPE) and Missouri Department of Health and Senior Services Bureau of Community Health and Wellness. If the student’s health care provider has not completed an EAP, the school nurse should develop one or use one of the templates from AAAAI, AAP, or FAPE and have the health care provider sign it. A very important component of the EAP is that it should be written with language that is easily understood by lay people as they are most likely the individuals who will be caring for the student during an anaphylactic event. The EAP should be updated at least annually and if there are any changes with the student’s health condition.

An important distinction to point out is that some of the EAPs templates differentiate when antihistamines should be administered versus epinephrine, other forms only include instructions for epinephrine administration. If the school nurse will be delegating epinephrine administration to an Unlicensed Assistive Personnel (UAP) and the EAP differentiates the symptoms that require the administration of antihistamines and not epinephrine, it is very important that the school nurse educate the UAP on what those symptoms look like.

An Emergency Action Plan for anaphylaxis should contain the following information:

Parent/Guardian Authorization: In addition to the health care provider’s order, the school nurse will also need written authorization from the parents/guardians to administer epinephrine (except for when administering stock epinephrine for a student with an undiagnosed anaphylactic allergy). The EAP templates developed by AAAAI, AAP, and FAPE include a section for parent authorization. If the parent authorization is not included or the health care provider just provides an order for the epinephrine, then the school nurse will want to document the parent/guardian authorization on a separate document.

Self-Possession and Administration: When determining if a student is capable of carrying and self-administering the epinephrine the school nurse will want to meet with the student and assess their knowledge, ability, and skills to ensure that it is appropriate for them to self-possess and self-administer their epinephrine. Upon completing this assessment the school nurse will want to document their assessment in the student’s health record. The school nurse should also document that the student’s parent/guardian and health care provider agree with the plan of care for the student to self-carry and self-administer their medication. If the student were to self-administer their epinephrine, the school nurse would want to ensure the self-administration is documented in the student’s health care record.

The National Association of School Nurses has developed a Contract for Student Self-Carry and Self-Administration of Medication that could be used to document the school nurse’s assessment and planning with the student.

Sample documents: Permission for Student to Self-Carry and Self-Administer Epinephrine[1]  from Parkway Schools  and a fillable template Authorization for Students to Self-Carry from St. Louis Children’s, Food Allergy Management and Education Program.

Procedures and Medication Administration: Administration of epinephrine will need to be documented, whether it is administered by the school nurse, a UAP, or if the student self-administered. The medication administration should be documented in the student’s health record. The school nurse will want to ensure that the documentation is completed for the administration of epinephrine during field trips, before or after school, and/or during any school-sponsored activities. 

Staff Competency Validation: If the epinephrine administration is delegated to a UAP the school nurse should document that the UAPs knowledge, abilities, and skills have been assessed. Many times these factors are documented on a skills competency checklist (see Respiratory Just in Time Skill Competency Checklists). There should be a place on the skills competency checklist for the school nurse and UAP to sign to indicate that they feel competent and are willing to perform the procedure. Once the procedure has been delegated the school nurse is responsible for periodic evaluation of the UAP and their competency. The school nurse must determine how often the supervision is needed. After the school nurse has re-evaluated the UAP’s competency, they should document the date of the evaluation (Shannon & Kubelka, 2013; Selekman & Ness, 2019). The school nurse should organize the competency documentation in a way that easily allows them to determine when subsequent evaluation and documentation of competency is needed. For more information on delegation see the Delegation section.

Individualized Health Care Plan (IHCP): Another document that the school nurse may develop for a student with anaphylactic allergies is an Individualized Health Care Plan (IHCP). The IHCP outlines the plan of care for the student, including but not limited to:

  • Actions taken by the school nurse to support the student’s educational attainment.
  • The education and training that will be provided to school personnel.
  • The education and training the school nurse will provide to the student to assist them in being able to self-possess and self-administer their epinephrine.
  • The education the school nurse will provide to the student to assist them in being able to reduce their risk of anaphylaxis.
  • The development of Emergency Action Plans, including steps to be taken in case of an evacuation.
  • And the accompanying expected outcomes for each of the nursing interventions (NASN, 2020c).

Prior to completing the IHCP, the school nurse should complete a health history and physical assessment of the student. For more information on health history see the student section.

A sample Severe Allergies IHCP developed by the National Association of School Nurses.

Section 504 Plan: Students with anaphylactic allergies may qualify for a Section 504 Plan since their health condition may impact a major life activity (breathing). If the student has been identified as qualifying for a 504 Plan, the school nurse may be involved in identifying appropriate accommodations and writing the plan. Once developed, the school nurse will want to frequently review, update, and document in the 504 Plan (NASN, 2020c). For more information on Section 504 Plans see Legal Issues section.

Procedures

Just in Time > Respiratory Procedures

Emergency Preparedness

Shelter-in-Place and Other Emergency Events:

In addition to ensuring all students with diagnosed anaphylaxis have an Emergency Care Plan (see Documentation section) and that all school staff have been educated on the signs and symptoms of anaphylaxis and how to respond to an emergency (see School Environment); the school nurse must also plan for other potential emergencies such as lockdown, extreme weather events, evacuations, and shelter-in-place events. To develop plans to address these possible emergencies the school nurse would want to collaborate with other school staff and administrators. The emergency preparedness plan should address the following:

  1. Location of epinephrine in case of lock-down or shelter-in-place.
  2. Adequate supply of safe, non-perishable foods for students with anaphylaxis.
  3. Additional accommodations that may be required during an emergency (i.e., extra staff to help support the student’s needs).

(Food Allergy Research and Education, 2023b)

For more information on emergency planning see Missouri School Boards’ Association’s Emergency Planning Guide for Students and Staff with Special and Functional Needs within Schools.

There are currently three Missouri State Statutes that relate to anaphylaxis management in the school setting. They are:

Section 504 Plan:

Students with anaphylactic allergies may qualify for a Section 504 Plan. Section 504 of the Rehabilitation Act of 1973 as amended through the Americans with Disabilities Amendment Act (ADAA) in 2008 ensures that students who have disabilities have access to a free and appropriate public education (FAPE) (U.S. Department of Education, 2023).  FAPE provides a student with a physical or mental impairment that impacts one or more major life activities (including breathing) with related services and accommodations in the general education classroom (U.S. Department of Education, 2023; NASN, 2023c).  If the student does not have a 504 Plan the school nurse should determine if an evaluation is indicated (see Students section for questions to ask student and family to determine if 504 evaluation is indicated). If it is determined that the student qualifies for a Section 504 Plan, the school nurse may want to consider the appropriateness of the following accommodations:

  • The student will self-carry two epinephrine auto-injectors at all times (age dependent).
  • The student will have access to safe foods in the case of an emergency shelter-in-place.
  • The student will have access to trained transportation staff who know how to respond to food allergy emergencies.
  • The student will not be excluded from field trips or the ability to participate in extracurricular activities.
  • The school will provide the student with substitutions or modifications to school meals, as needed.
  • The school will provide the student’s parent/guardian with copies of all breakfast and lunch menus to allow them to address potential concerns.

(Food Allergy and Anaphylaxis Connection Team, 2023; St. Louis Children’s Hospital, 2017-2022a)

The above list is not all inclusive, for more information on possible accommodations see Food Allergy and Anaphylaxis Connection Team and St. Louis Children’s Hospital, Food Allergy Management and Education for more suggestions). 

Resources

Missouri Resources:

Emergency Action Plan Templates:

Forms:

Guidelines:

Toolkits:

Education and Training:

Other:

References

American Academy of Allergy, Asthma & Immunology. (2020, September 28) When should children and adolescents assume responsibility for self-treatment of anaphylaxis? Available at: https://www.aaaai.org/tools-for-the-public/conditions-library/allergies/children-epinephrine

American Academy of Allergy, Asthma & Immunology. (2021, October). Epinephrine myths vs. facts.

American Academy of Allergy, Asthma & Immunology. (2023). Anaphylaxis.

American College of Allergy, Asthma, & Immunology. (2018, January 29). Anaphylaxis.

American Nurses Association. (2012). Principles of delegation.

Centers for Disease Control and Prevention. (2013). Voluntary guidelines for managing food allergies in schools and early care and education programs. Washington, DC: US Department of Health and Human Services.

Davis, C. M., & Kelso, J. M. (2018). Food allergy management. Immunology and Allergy Clinics of North America, 38, 53-64. https://doi.org/10.1016/j.iac.2017.09.005

Division of Population Health, National Center for Chronic Disease Prevention and Health Promotion. (2022, August 23). Food allergies.

Duffy, (2024). Chapter 23: The child with fluid and electrolyte imbalance. In Hockenberry, Duffy, & Gibbs (Eds). Wong’s nursing care of infants and children (12th Ed., p. 757).

Epinephrine prefilled auto syringes, school nurse authorized to maintain adequate supply — administration authorized, when. Missouri Revised Statute: 167.630 RSMo. (2010).

Erwin, K., Clark, S., & Mercer, S.E. (2014). Providing health services for children with special health care needs on out-of-state field trips. NASN School Nurse, 29(2), 84-8.

Food Allergy and Anaphylaxis Connection Team. (2023). Accommodations.

Food Allergy Research and Education. (2019). How might a child describe a reaction?

Food Allergy Research & Education. (2020, May). Food allergy & anaphylaxis emergency care plan.

Food Allergy Research & Education. (2023a). Recognizing and treating reaction symptoms.

Food Allergy Research and Education. (2023b). Shelter-in-place school emergency.

Gereige, R. S., Gross, T., Jastaniah, E. & Council on School Health and Committee on Pediatric Emergency Medicine. (2022). Individual medical emergencies occurring at school. Pediatrics, 150(1), 1-16.

Missouri Department of Health and Senior Services. (2014). Guidelines for allergy prevention and response.

Missouri Department of Health and Senior Services Bureau of Community Health and Wellness. (2021). SN chat. School nurse chronic health assessment tool.

Moritz, S., & Schoessler, S. (2018). Steps to stock: Keeping students safe with fully implemented stock epinephrine. NASN School Nurse (Print), 33(5), 268–271.

National Association of School Nurses. (n.d.). Family food allergy health history form.

National Association of School Nurses. (2018). Food allergies and anaphylaxis. Sample checklist for training school personnel.

National Association of School Nurses. (2019a). School-sponsored trips -The role of the school nurse (Position Statement). Silver Spring, MD: Author.

National Association of School Nurses. (2019b). Transition planning for students with healthcare needs (Position Statement). Silver Spring, MD: Author.

National Association of School Nurses. (2020a). Emergency medication administration delegation. Decision tree.

National Association of School Nurses. (2020b). Emergency medication toolkit.

National Association of School Nurses. (2020c). Understanding student health and education plans.

National Association of School Nurses. (2023a). Allergy and anaphylaxis checklist to initiate and sustain stock epinephrine programs.

National Association of School Nurses. (2023b). Allergy and anaphylaxis training for all school staff-checklist.

National Association of School Nurses. (2023c). IDEIA and Section 504 Teams – The school nurse as an essential team member (Position Statement). Author.

National Association of School Nurses. (2023d). Sample severe allergy health history intake form.

National Association of School Nurses. (2023e). School nursing evidence-based clinical practice guideline: Students with allergies and at-risk for anaphylaxis.

Northern Health. (2022, May). Resource guide for allergy aware schools.

Possession and self-administration of medication in school—requirements. Missouri Revised Statute: 167.627 RSMo. (2010).

School Access to Emergency Epinephrine Act Public Law 113–48 127 STAT. 575. (2013).

Selekman, J. & Ness, M. (2019). Students with chronic conditions. In J. Selekman, R.A. Shannon, C.F. Yonkaitis, (Eds.). School nursing, a comprehensive text (3rd ed., p 493). Philadelphia PA.: F. A. Davis Co.

Shannon, R. A., & Kubelka, S. (2013). Reducing the risks of delegation: use of procedure skills checklists for unlicensed assistive personnel in schools, Part 2. NASN School Nurse (Print), 28(5), 222–226.

St. Louis Children’s Hospital, Food Allergy Management and Education Program. (2017-2022a). 504 plan.

St. Louis Children’s Hospital, Food Allergy Management and Education Program. (2017-2022b). Instructions to complete an individual health care plan (IHP).

U.S. Department of Education. (2023). Frequently asked questions about Section 504 and the education of children with disabilities.

U.S. Department of Health and Human Services & U.S. Department of Education. (2008). Joint guidance on the application of the Family Educational Rights and Privacy Act (FERPA) the Health Insurance Portability and Accountability Act of 1996 (HIPAA) to student health records.

Wisconsin Department of Public Instruction. (2019). Meeting student health needs while on field trips. Tool kit for Wisconsin schools.

Reviewers

Renee Falkner, BSN, RN
School Nurse Supervision Specialist | Therapylog

Katherine Park, DNP, RN, NCSN
Nationally Certified School Nurse, Pierremont Elementary
Adjunct Professor, Maryville University School of Nursing

Last reviewed 4/18/2025

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