Asthma-action-plan

ASTHMA ACTION PLAN & AUTHORIZATION FOR MEDICATION
TO BE COMPLETED BY PARENT:
Child’s Name
Name of Physician/Nurse Practitioner/Physician Assistant What triggers your child’s asthma attack: (Check all that apply)
͘ Illness
Food _________________________________________ Allergies: ͘ Cat ͘ Dog ͘ Dust ͘ Mold ͘ Pollen ͘ Other ________________________________________
Describe the symptoms your child experiences before or during an asthma episode: (Check all that apply)
͘ Cough
͘ Other ________________________________________
TO BE COMPLETED BY HEALTH CARE PROVIDER:
The child’s asthma is: ͘ Intermittent ͘ Mild Persistent ͘ Moderate Persistent ͘ Severe Persistent ͘ Exercise-Induced
Peak Flow
Symptoms OR Monitoring
Treatment
Controllers & Relievers
͘ Inhaled Corticosteroid ________
Personal
Leukotriene Modifier:
͘ Other__________________
Relievers
͘ 2 puffs or 1 nebulizer
treatment 5 min. before
4-6 hrs. as needed
physical activity
1. ͘ Continue daily controller medications 2. ͘ Give albuterol 2-6 puffs (1 min. between puffs) with spacer or 1 nebulizer treatment, wait 3. ͘ If no improvement, repeat 2-6 puffs or 1 nebulizer treatment, wait 20 min. Call parent and/or
If no improvement, CALL 911
If child returns to Green Zone:
͘ Continue to give albuterol 2 puffs every 4 hours for 1 to 2 more days ͘ No physical exercise ͘ Physical exercise as tolerated i.e. PE & recess at school EMERGENCY!
͘Give albuterol (2-6 puffs (with spacer) or 1 nebulizer treatment NOW! May repeat
once after 20 min.
If there is no improvement, call parent and/or 911.
<________
Call 911 immediately if:
Child is struggling to breathe and there is no improvement 20 minutes after taking albuterol Child has lips or fingernails that are gray or blue Child’s chest or neck is pulling in with breathing PATIENT/STUDENT INSTRUCTIONS:
͘ Student has been instructed in the proper use of all his/her asthma medications, and in my opinion, the student can carry and use his/her inhaler at school
͘ Student is to notify his/her designated school health officials after using inhaler per school protocol
͘ Student needs supervision or assistance to use his/her inhaler ͘ Student shall NOT be able to carry his/her inhaler while at school
͘Valid for current school
HEALTH CARE PROVIDER SIGNATURE
PLEASE PRINT PROVIDER’S NAME
I give permission for school personnel to follow this plan, administer medication and care for my child and contact my physician if necessary. I assume full responsibility for providing the school with prescribed medication and delivery/monitoring devices. I approve this Asthma Management Plan for my child. PARENT SIGNATURE
Virginia Asthma Coalition
cc: principal____ office staff____ librarian____ cafeteria mgr.____ bus driver/transportation____ Coach/PE____ teachers____ revision 3/07

Source: https://www.pediatricare.com/files/asthma-action-form.pdf