OFFICE OF CATHOLIC SCHOOLS DIOCESE OF ARLINGTON ASTHMA ACTION PLAN PROCEDURES ON REVERSE TO BE COMPLETED BY PARENT:
Student ________________________________________ DOB _____________ School ___________________________________ Grade __________ Emergency Contact ________________________________________________ Relationship _______________________ Phone __________________
What triggers your child’s asthma attack: (Check all that apply)
Food ________________________________________________
Other __________________________________________________
Describe the symptoms your child experiences before or during an asthma episode: (Check all that apply) TO BE COMPLETED BY LICENSED HEALTH CARE PROVIDER: The child’s asthma is: mild persistent moderate persistent severe persistent EXERCISE-INDUCED Symptoms Peak Flow Treatment (For medication administered during school sanctioned activities, complete appropriate Inhaler/ Medication Authorization form) GREEN ZONE Controller > ____________ Relievers YELLOW ZONE 1. Continue daily controller medications 2. Give albuterol 2-4 puffs (one minute between puffs) with spacer or 1 nebulizer treatment, wait 20 min.
? If no improvement, repeat 2-4 puffs. Wait 20 minutes.
_____ to ______
? If no improvement, repeat 2-4 puffs. This will be 3 doses in one hour, proceed to 3
3. If child returns to Green Zone:
? Continue to give albuterol 2 puffs every 4 hours for 1 to 2 more days
? Increase controller to _______________________________________ for next 7 days
4. ? No physical exercise If child remains in Yellow Zone for more than 1-2 days or requires albuterol more than every 4 hours, call your doctor NOW! Give albuterol (2 puffs with spacer) NOW, and repeat every 20 minutes for 2 more doses OR give 1 EMERGENCY! dose nebulized albuterol – Call your doctor Seek emergency care or call 911 if: < ____________
? Child is struggling to breathe and there is no improvement 20 minutes after taking albuterol
? Lips or fingernails are gray or blue ? Chest or neck is pulling in with breathing
? Student is able to perform procedure alone and may carry
? Student is able to perform procedure with supervision
the inhaler with them, consult school nurse for local protocol
? Student requires a staff member to perform procedure
? More than 2 absences related to asthma per month ? Albuterol is being used as a rescue medication 2 times per week at school
? The child is persistently in the Yellow Zone
___________________________________________
I approve this Asthma Action Plan for my child. I give my permission for school personnel to follow this plan, release the information contained in this management plan to all adults who have custodial care of my child and who may need to know this information to maintain my child’s health and safety and contact my physician if necessary. I assume full responsibility for providing the school with prescribed medication and delivery/monitoring devices. _______________________________________
Adapted from: Virginia Department of Health, Virginia Department of Education. (2004) Guidelines for Specialized Health Care Pro OFFICE OF CATHOLIC SCHOOLS DIOCESE OF ARLINGTON ASTHMA ACTION PLAN TO BE COMPLETED BY PRINCIPAL OR REGISTERED NURSE Student _______________________________________________ School ___________________________ Teacher/Grade ____________ Parent/Caregiver ________________________________ Phone (H) _______________ Phone (W) ________________ Phone (Cell) ______________ Physician _____________________________________________________________ Office phone number ___________________________ ASTHMA ACTION PLAN CHECK LIST FOR SCHOOL PERSONNEL
• Asthma Action Plan Part I and II, complete
• Medication maintained in school designated area
_____________________ _____________________
• Staff trained in medication administration
• Copies of plan provided to: Educational yes
After school yes
Food service yes IMMEDIATE ACTION FOR SYMPTOMS IF YOU SEE THIS:
5. Allow student to rest 6. If no improvement in 15 minutes, repeat
IF YOU SEE THIS DO THIS IMMEDIATELY
Stooped over posture Trouble walking or talking Lips or fingernails are gray or blue
Full Asthma Action Plan has been implemented. _____________________________________
Adapted from: Virginia Department of Health, Virginia Department of Education. (2004) Guidelines for Specialized Health Care Procedures
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