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Asthma Action Plan

 

Student Name  ___________________________       Teacher/Team ____________________________

 

1.   Triggers that might start an asthma episode for this student:

 (please circle)

Exercise

Animal Dander

Cigarette smoke, strong  odors

Respiratory Infections

Pollens

Temperature Changes

Foods

Emotions(e.g., when upset)

Molds

Irritants (e.g., chalk dust)

Other, Please list

 

 

2.   Control of the School Environment:

 

______    Environmental measures to control triggers at school _________________________________

______    Pre-Medications (prior to exercise, choir, band, etc.) _________________________________

______    Dietary Restrictions ___________________________________________________________

 

3.   Peak Flow Monitoring

______    Monitor Peak Flow:

               Personal Best Peak Flow ____________________    Monitoring Times ___________________

 

______    Do Not Monitor Peak Flow

 

4.   Routine Asthma and Allergy Medication Schedule

Medication Name

Dose/Frequency

When to Administer

At Home

At School

 

 

 

 

 

 

 

 

 

 

 

 

 

5.   Field Trips:  Asthma medications and supplies must accompany student on all field trips.  Staff members must be instructed on correct use of the asthma medications and bring a copy of the Asthma Action Plan/Quick Relief Emergency Plan and the contact phone numbers.

a)   Parent to Contact______________________________________________________________

Phone Number(s)______________________________________________________________

b)   Other Person to Contact in Emergency______________________________________________

Phone Number(s)______________________________________________________________

 

Parent/Legal Guardian Signature________________________________ Date                                        

 

Reviewed by the School Nurse__________________________________ Date____________________

Please review other side

 


 

School Asthma Quick Relief & Emergency Plan

 

**    Immediate action is required when the student exhibits any of the following signs of respiratory distress.  Always treat symptoms even if a peak flow meter is not available.

 

Severe cough

Turning blue

Blueness of fingernails & lips

Chest tightness

Rapid, labored breathing

Difficulty walking from breathing

Wheezing

Sucking in of the chest wall

Difficulty talking from breathing

Shortness of Breath

Shallow, rapid breathing

Decreased or loss of consciousness

 

Steps to Take During an Asthma Episode:

 

1.   Give Emergency Asthma Medications as Listed Below:

 

Quick Relief Medications

Dose/Frequency

When to Administer

1.

 

 

 

2.

 

 

 

 

2.  Contact Parents if ________________________________________________________________

 

3.  Call __________________________  to activate EMS if the student has ANY of the following:

 

·         Lips or fingernails are blue or gray

·         Student is too short of breath to walk, talk, or eat normally

·         No relief from medication within 15-20 minutes with any of the following signs:

?          Chest and neck pulling in with breathing

?          Child is hunching over

?          Child is struggling to breathe

 

Parent Consent for Management of Asthma at School

 

I, the parent or guardian of the above named student, request that this school Asthma Action Plan be used to guide asthma care for my child.  I agree to:

1.   Provide necessary supplies and equipment.

2.   Notify the school nurse of any changes in the student’s health status.

3.   Notify the school nurse and complete new consent for changes in orders from the student’s health care provider.

4.   Authorize the school nurse to communicate with the primary care provider/specialist about asthma/allergy as needed.

5.   Allow school staff interacting directly with my child to be informed about his/her special needs while at school.

 

Parent/Legal Guardian Signature _______________________________   Date __________________

 

Review by School Nurse _______________________________________   Date __________________

 

 

 

ASTHMA MEDICATION SELF-ADMINISTRATION FORM

Student Name: _________________________________________________ Teacher: _____________

 

The Missouri Safe Schools Act of 1996 provides for students to carry and self-administer lifesaving medications when the following criteria are met:

1) Written authorization by the parent/guardian

2) Medical history of students asthma on file at the school

3) Written asthma action plan/individual healthcare plan on file at school

4) Written authorization from the prescribing health care provider that child has asthma, has been trained

in the use of the medication and is capable of self-administration of the medication.

 

 

MEDICATION NAME ___________________________________ Dose ______________

Time or Interval _____________

Route/Inhalation device ____________________________________________________________________

Instructions ______________________________________________________________________________

________________________________________________________________________________________

MEDICATION NAME ___________________________________ Dose ______________ Time or Interval _____________

Route/Inhalation device _________________________________________Instructions ______________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

ALLERGIES: list known allergies to medications, foods, or air-borne substances _______________________

____________________________________________________________________________________________________

I, the parent or legal guardian of the student listed above, give permission for this child to carry and self-administer the

above listed medications. I have instructed my child to notify the school staff if one dose fails to relieve asthma symptoms

for 3 or more hours. I understand that, absent any negligence, the school shall incur no liablity as a result of any injury arising

from the self-administration of medication by my child.

Signature of parent or legal guardian ________________________________________________ Date __________

Parent/Guardian:

Name: ________________________________________________________________

 Home phone: ______________________ Work phone:

Address: _______________________________________________________________ ______________________

Name: ________________________________________________________________ Home phone: ____________

Address: _______________________________________________________________Work phone: ______________________

Emergency Contact:

Name: ________________________________________________________________________ Phone: ______________________

I, a licensed health care provider, certify that this child has a medical history of asthma, has been trained in the use of the

listed medication, and is judged to be capable of carrying and self-administering the listed medication(s). The child should

notify school staff if one dose of the medication fails to relieve asthma symptoms for at least 3 hours. This child understands

the hazards of sharing medications with others and has agreed to refrain from this practice.

Signature of Health Care Provider ____________________________________________________ Date __________________

Healthcare Provider:

Name: _____________________________________________________________________________________________

Fax: _____________________________________________________ Phone: _____________________________

Address: _________________________________________________City: ___________________________Zip: __