Severe Allergic Reaction Toolkit for School Nurses

Disclaimer: This toolkit is intended to provide resources for school nursing practice as it relates to the care of students with severe allergic reactions. This is not medical or nurse practice advice, and is not prescriptive as it relates to individual students or individual nursing practice. These resources do not override individual assessment and clinical judgement.

Anaphylaxis is a common, potentially fatal systemic immune reaction. The incidence of anaphylaxis has been on an increasing trend, and considered to be highly under-reported (Canon et al., 2019; Tanno et al., 2018). The most common causes of anaphylaxis in children include food, medication, and insect venom; although rare, these reactions may prove to be fatal (Okubo , Nochioka & Testa, 2019; Wang et al., 2017; Turner et al., 2017; Tanno et al., 2018). The single most important factor related to an individual surviving anaphylactic reaction in the community setting is how quickly they receive a dose of epinephrine and whether or not follow up medical care is received ( Wang et al., 2017). Individualized emergency plans are an appropriate standard of care for children with known anaphylactic reactions. The plans should be formulated by specialists and the school nurse should facilitate this information by implementing appropriate training, education, planning and procedures with school staff. In addition, school nurses should facilitate standardized procedures to account for students (~18%) who will experience their first anaphylactic reaction at school (Tyner et al., 2019; Canon et al., 2017). Literature robustly states that all schools should have stock doses of epinephrine and comprehensive staff training, policies and procedures to ensure safety of all students related to anaphylaxis ( Canon et al., 2017,. Tuner et al, 2017; Wang et al., 2017). 

Evidence Based Practice

Literature Review

Basic Disease Information

To review the pathophysiology of Anaphylaxis:

  • Reber, L. L., Hernandez, J. D., & Galli, S. J. (2017). The pathophysiology of anaphylaxis. The Journal of allergy and clinical immunology, 140(2), 335–348.

Legal Practice Standards

At the forefront of nurse case management for school nurses, is the understanding of scope of practice as it relates to case management and delegation of nursing tasks in a community setting:

Nurse Practice

Oregon Revised Statutes pertaining to medication administration and written individual plans in Oregon School. ORS 339 [School Attendance, Admission, Discipline, Safety]

  • 339.866 Self-administration of medication by students.
  • 339.869 Administration of medication to student.

Oregon Revised Statutes pertaining  to SAR and Epinephrine in Oregon ORS 433.800

  • 433.805 Legal obligation to provide response to Severe Allergic Reaction
  • 433.815 Educational Training of Severe Allergic Reaction and Epinephrine Administration
  • 433.817 OHA Approved Training
  • 433.825 Availability of Doses of Epinephrine

Oregon Administrative Rules pertaining to SAR and Epinephrine in Oregon

Public Access Practice Resources

The professional nurse in the school setting should understand and access existing resources and framework for care of students with severe allergies. 

Note: the following are national or regional resources that serve as a reference, they may or may not be consistent with Oregon law and do not supersede Oregon Nurse Practice or clinical judgment.

National Association of School Nurses (NASN)

Centers for Disease Control and Prevention(CDC)

Food Allergy Research and Education (FARE)

American Academy of Allergy, Asthma, and Immunology

Professional Development

Nurses must ensure that they have proficiency in areas of practice in which they train and delegate. The following include Free Continuing Education resources for Nursing related to SAR:

Public Access Video Education

Cleveland Clinic

Nurse CE 4 Less

    UAP Training

    In the state of Oregon there is specific training required for care of students with severe allergic reaction or emergency medication that are prerequisite to individualized training. These include medication administration and epinephrine administration.

    Oregon Department of Education (ODE)

    Oregon Health Authority (OHA)

    Anaphylaxis Animations

    Refresher Videos

    UAP Checklist

    Nurses may want to consider documentation of skill validation as it relates to competency of SAR response and epinephrine administration for UAPs.

    Stock Epinephrine

    Stock epinephrine is a critical piece of school safety.  Anaphylaxis is a common condition among pediatric populations.  Severe allergic reactions without previous occurrence occur in approximately 25% of anaphylactic reactions. Nearly 40% of epinephrine administered at school is from stock supplies ( White, et al., 2016; Cannon, Gharfeh & Guffrey, 2019)

    Medication Sites

    Standing Orders Samples

    Individualized Templates

    The following templates are modifiable for use by school nurses as they relate to their practice and should be used consistently with Oregon State Board of Nursing, Delegation laws and local school policy. 


    Some nurses may find it helpful to develop a list that identities the priority elements associated with SAR management at school and an itemization of individual responsibilities. 

    Individualized Health Plans

    An individualized health plan is the totality of the plan that includes all applicable procedures for students with chronic disease. This may include more than one diagnosis. For students with severe allergic reactions, they may also have comorbid mild reactions and asthma. It is critical that the specialists are the drivers of the tiered approach to respond to the variety of presentations a student may experience with comorbid allergic conditions. Because these are intended to be individualized, the attached is an example of a compiled IHP:

    Nursing Care Plan

    For districts that use nursing care plans, the following editable template is available:


    Teacher Notification

    Teacher notifications, sometimes referred to as health status notifications, or health information pages can be used or combined with or in lieu of  emergency action plans to ensure that all staff working with a student with a severe allergy are informed of diagnosis and immediate actions when necessary, these are abbreviated documents to provide critical information, but less comprehensive information than a complete IHP.


    An individual's history should be collected on all students with known anaphylaxis. When individualizing a health plan and training, known allergens and a history of specific symptoms is highly important. 

    Providers Orders

    Obtaining orders for epinephrine and other medications may be necessary when the prescription label for epinephrine is non specific, such as “use as directed.”  Rather, the order should indicate whether epinephrine is administered upon exposure to allergen or onset of symptoms. In addition, the evidence related to administration of antihistamines contains significant conflict due to the potential to mask progression of significant symptoms. When antihistamines are included in an anaphylaxis plan, it should be done under the orders of an allergy specialist. 


    Because injectable medications fall outside routine medication administration training, many nurses will add an additional layer of authorization for permission to administer that includes context, the method of administration and the laws around designated persons. 

    Self Medication of Epinephrine Assessment

    Prior to self administration, nurses may want to consider self management assessment of a student who will carry their own epinephrine auto injector. 

    Medication Administration and Self-Medication Agreement



    Author: Jan Olson

    Peer Reviewers:
    Lead: Courtney Szper
    Kristiina Gagner
    Molly Blackburn
    Juilie Turner

    Editorial Reviewer: Wendy Niskanen


    Okubo, Y., Nochioka K., Testa M.A. (2019). Nationwide survey of hospitalization due to pediatric food-induced anaphylaxis in the United States. Pediatr Emerg Care. 35: 769-773.

    Tanno, L.K., Bierrenbach, A.L., Simons, F.E.R. et al. (2018). Critical view of anaphylaxis epidemiology: Open questions and new perspectives. Allergy Asthma Clin Immunol, 14.

    Turner, P. J., Jerschow, E., Umasunthar, T., Lin, R., Campbell, D. E., & Boyle, R. J. (2017). Fatal anaphylaxis: Mortality rate and risk factors. The Journal of Allergy and Clinical Immunology. In Practice, 5(5), 1169–1178.

    Tyner, P.J., Campbell, D.E., Motosue, M.S., Campbell, R.L. (2019). Global trends in anaphylaxis epidemiology and clinical implications. The Journal of Clinical Immunology, 8(4), 1169-1176.

    Wang, J., Bingemann, T., Russell, A., Young, M.C., Sicherer, S.H. (2018). The allergists' role in anaphylaxis and food allergy management in the school and childcare setting. Journal of Allergy and Clinical Immunology: In Practice, (6)2, 427-435. 1016/j.jaip.2017.11.022

    White, M. V., Hogue, S. L., Odom, D., Cooney, D., Bartsch, J., Goss, D., Hollis, K., Herrem, C., & Silvia, S. (2016). Anaphylaxis in schools: results of the EPIPEN4SCHOOLS survey combined analysis. Pediatric Allergy, Immunology, and Pulmonology, 29(3), 149–154.