Asthma_careplan_201

School Nurse’s Office Only:
Inhaler Expires: _____________________
Student Carries Inhaler: Yes ____No ____
STUDENT ASTHMA ACTION PLAN
Name: _____________________________________________ Grade: ____________ Age: ____ Teacher: ____________________________________________ Parent/Guardian Name: ________________________________ Phone: _____________________ Parent/Guardian Name: ________________________________ Phone: _____________________ Emergency Phone Contact #1: ___________________________________________________________ Emergency Phone Contact #2: ___________________________________________________________ Treating Physician for Asthma/Phone: ____________________________________________________ HISTORY: When was the student diagnosed with asthma? ________________________________________________
How often does an episode occur? ____________________________________________________________________ List recent hospitalizations and/or visits to Urgent Care for asthma or respiratory episodes. _______________________ Check any conditions that TRIGGER an episode:
For Exercise Relief:

Albuterol MDI (please circle) Ventolin or Proventil 2-4 puffs with spacer 15-30 minutes before exercise.
Immediate action is required when the above named student exhibits any of the following signs of an
asthma attacks: Repetitive Cough Shortness of breath Chest tightness Wheezing Retractions

For Emergency Relief:
Quick Relief Medication
Frequency
Additional Medication provided: _______________________________________________________________ Peak Flow Monitoring: ______________________________________________________________________ Comments/Special Instructions: _______________________________________________________________ Holy Innocents’ Episcopal 805 Mount Vernon Hwy, N.W. Atlanta, Georgia 30327 Activate EMS (call 911) If the student has ANY of the following symptoms:

□ Lips or fingernails are blue or gray □ The student is too short of breath to walk, talk, or eat normally. □ The student gets no relief within 10-15 minutes of quick relief medicines. Persistent chest and □ Child is hunching over □ Child is struggling to breathe Parent Consent for Management of Asthma at School
I __________________________________________, the parent/guardian, of the above named student; request
this School Asthma Action Plan be used to guide asthma care for my child while at school.
I agree to:
1. Provide the necessary supplies and equipment for my child’s care. 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 primary care 4. Authorize the school nurse to communicate with my child’s primary care providers/specialist as needed. 5. To provide a separate MDI/spacer and a separate EpiPen is clinically appropriate to be used on field I agree that medications that have been prescribed for my child’s use may be administered by a school nurse or authorized staff member if: 1. The medication has been appropriately labeled by a pharmacist under the direction of a licensed health 2. I as the parent or legal guardian have granted permission below for the specific medication(s) to be Equipment (excluding medications) that I have provided for use by my child includes:
Signature of Parent/Guardian: ______________________________________________ Date: ______________ Reviewed by School Nurse: _______________________________________________ Date: ______________ Holy Innocents’ Episcopal 805 Mount Vernon Hwy, N.W. Atlanta, Georgia 30327 Holy Innocents’ Episcopal 805 Mount Vernon Hwy, N.W. Atlanta, Georgia 30327

Source: http://www.hies.org/ftpimages/219/download/Asthma_Careplan_2013.pdf