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Anaphylaxis in the school setting

By: John T. Taylor, DNP, RN, CPN, and Heidi Hildick, MSN, RN, CPN

Quick action results in positive outcome. 


  • School mealtimes are important for socialization and nutrition, but food allergies can be life-threatening.
  • Quick assessment and action by school nurses are essential to help students in distress.
  • School nurses partner with students, families, and teachers to keep students safe at school.

Chloe Johnson* is a 6-year-old student at the school where you work. Your only encounters with her have been for routine screenings. She has no past medical history and no documented allergies. She doesn’t take any regular medications, and her immunizations are up to date as of the beginning of the school year.

Today, her teacher calls you to the classroom because Chloe is short of breath. You take your emergency kit and oxygen tank with you.

History and assessment findings

When you enter the classroom, Chloe is sitting on the edge of her chair. She’s leaning her upper body forward and resting her hands on her knees. Her breathing is labored, and she’s shrugging her shoulders with each breath. You note that Chloe’s lips and eyelids are swollen. Her vital signs are temperature 98.9° F (37° C), heart rate 136 beats per minute, respiration 36 breaths per minute, blood pressure 100/70 mmHG, and pulse oximetry 84% on room air.

Chloe can speak only in short phrases between deep breaths. You ask her what she had for lunch, and she gasps her reply: “I tried this green fuzzy fruit I’ve never had before. I think it’s called kiwi.” Chloe’s poor air exchange makes hearing breath sounds difficult.

Taking action

Fearing respiratory distress related to allergic anaphylaxis, you place Chloe on 6 L of supplemental oxygen via facemask. You radio the school office and ask the secretary to call 911 and to send another adult to help you.

Chloe’s respiratory effort and vital signs improve only slightly with the supplemental oxygen. When the second adult arrives, he tells you that in addition to calling 911, the secretary called Chloe’s parents.

You know that Chloe will require an intramuscular epinephrine injection to treat the anaphylactic reaction, so you prepare the pediatric dose (0.15mg/0.3mL) epinephrine auto-injector that’s in your emergency kit. You tell Chloe that she’ll experience a big pinch in her leg for a few seconds but that it will make her feel better soon. Following the manufacturer’s instructions, you administer the epinephrine into the right vastus lateralis muscle (lateral middle-third of the thigh between the greater trochanter and the knee). After safely removing the auto-injector from the injection site, you gently massage the site for 10 seconds to promote medication absorption.


Within a few minutes of receiving the epinephrine injection, Chloe’s respiratory effort improves with less labored breathing. Her mother and emergency medical personnel (EMS) arrive shortly after, and you provide a handoff of the situation, including the time of epinephrine administration. After the EMS team departs with Chloe, you document the events and the epinephrine administration in the school’s electronic health record.

Education and follow-up

Because Chloe has experienced a new reaction to an unknown allergen, you work with her parents and pediatrician to ensure she receives a referral to an allergist.

In accordance with school district guidelines, you collaborate with Chloe’s physician to establish a food allergy action plan, including emergency medications to give in the event of another reaction. When Chloe returns to school, you meet with her, her parents, and her teacher to discuss avoiding new foods at lunchtime until her allergen status is better understood.     AN

*Name is fictitious. To view a list of references, visit myamericannurse.com/?p=69668.

John T. Taylor is an associate professor of nursing at West Chester University in West Chester, Pennsylvania. Heidi Hildick is the lead school nurse for the Colonial School District in New Castle, Delaware.


Centers for Disease Control and Prevention. Voluntary Guidelines for Managing Food Allergies in Schools and Early Care and Education Programs. 2013. cdc.gov/healthyschools/foodallergies/pdf/13_243135_A_Food_Allergy_Web_508.pdf

Food Allergy Research & Education. Living with food allergies: Back to school headquarters. foodallergy.org/living-food-allergies/food-allergy-essentials/back-school-headquarters

National Association of School Nurses. Allergies and anaphylaxis. March 2019. nasn.org/nasn-resources/practice-topics/allergies-anaphylaxis

Wang J, Sicherer SH. Guidance on completing a written allergy and anaphylaxis emergency plan. Pediatrics.2017;139(3):e20164005

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