Microsoft word - asthma action care plan 2010.doc

Physician and Parent School Asthma Management Plan

Students Name: ______________________________________________
DOB: ____________________________
Physician: __________________________________________________
Physician Phone: _______________________________ Physician Fax:


RESCUE: With Breathing Difficulties Give Rescue Medicine: ______________________________________
Administer ________ of ___________________________________ medicine. Observe student for twenty minutes after rescue medicine
administration or until breathing difficulties are relieved. If student is still experiencing breathing difficulties after 20 minutes:
IT IS IS NOT okay to repeat rescue treatment. Observe student for twenty minutes between treatments or until breathing
difficulties are relieved. It is okay to repeat rescue treatment a total of ______________ times to relieve breathing difficulties.
Puffs should be administered individually with 10 second breath hold, wait at least 30 seconds between puffs. If student's breathing difficulties are not relieved after the above maximal treatment, parents should be called to come pick-up child from school and notified of need for call to physician for urgent medical attention. If more than one rescue treatment is ever required to relieve breathing difficulties or student requires rescue treatment more than two times in one week, the parents should be notified of need to schedule physician office visit for poorly controlled asthma. If student is experiencing extreme shortness of breath or lips and fingernail beds are blue emergency medical services should be
called and rescue albuterol treatments given until EMS arrives.
SICK PLAN: During Asthma Flare-ups scheduled rescue treatments are needed:
For one week following an ER or physician office visit for an asthma flare-up or notification of sickness by parent: Administer
______________________ of _______________________ every four hours and before PE or other strenuous activities. If student
requires rescue treatment before four-hour treatment interval parents should be called to pick-up student and notified of need for
physician visit.

It is the responsibility of student's parent/guardian to notify the school nurse of student's asthma flare-up or chest cold and the need for scheduled treatments After 24hrs on the above sick plan treatment if the asthma symptoms do not improve or get worse parents should be called to pick up child and notified of need for physician visit. If after one week on sick plan all asthma symptoms do not disappear parent should be notified of need to schedule a physician office visit for poorly controlled asthma. All ER visits for asthma flare-up should be followed by a Physician Office visit within 3 days. Unless contrary to ER physicians judgment, it is okay for child to attend school until follow-up visit DAILY ASTHMA CONTROL: Name of Medication: __________________________________________________________
How many: ___________________ How many times a day: _________________________
Known Allergies and Asthma Triggers include: ________________________________________________________________ All asthmatics should avoid exposures to airway irritants like smoke, dust, and high levels of ozone. Needs inhaler with him/her at school. Student also needs inhaler available for rescue in Health Room.
Does not need inhaler with him/her at school. Student should go to health room for administration of this medication by school
nurse or designated school district employee. Does not need treatment with rescue inhaler before PE every day except during asthma flare-up.
I AGREE WITH SCHOOL AND HOME ASTHMA MANAGEMENT PLAN. My child has my permission to use inhaler at school as described in plan. I agree to communication of changes in my child/guardian's asthma condition and management plans between my child/guardian's school, hospital and physicians. I, as the person responsible for my child/guardian's medical care, will be included/informed of communication regarding my child's medical care. Guardian's Signature: ____________________________________________________ Date: ____________________________ I have seen this child, authorize inhaler use at school in health room according to plan, and agree with plans for management of student's asthma at home and school. Physician's Signature: ___________________________________________________ Date: _____________________________


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