Child Care Asthma Action/management Plan Template Page 2
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1
2ASTHMA EMERGENCY PLAN
ALLERGY EMERGENCY PLAN
Emergency action is necessary when the child has symptoms such as ______________ •
Child is allergic to: _____________________________________________________
______________________________________________________________________
_____________________________________________________________________
or has a peak flow reading at or below _______________________________________
_____________________________________________________________________
• Steps to take during an asthma episode:
•
Steps to take during an allergy episode:
1.
Check peak flow reading (if child uses a peak flow meter).
1.
If the following symptoms occur, give the medications listed below.
2.
Give medications as listed below.
2.
Contact Emergency help and request epinephrine.
3.
Check for decreased symptoms and/or increased peak flow reading.
3.
Contact the child’s parent/guardian.
4.
Allow child to stay at child care setting if: ______________________________
________________________________________________________________
5.
Contact parent/guardian
•
Symptoms of an allergic reaction include :
6.
Seek emergency medical care if the child has any one of the following:
(Physician, please circle those that apply)
→ No improvement minutes after initial
→Mouth/Throat: itching & swelling of lips,
treatment with medication.
tongue, mouth, throat; throat tightness;
IF THIS
→ Peak flow at or below _______________.
hoarseness; cough
→Skin: hives; itchy rash; swelling
→ Hard time breathing with:
HAPPENS, GET
→Gut: nausea; abdominal cramps; vomiting;
Ø Chest and neck pulled in with breathing.
Ø Child hunched over.
diarrhea
EMERGENCY
Ø Child struggling to breathe.
→Lung*: shortness of breath; coughing; wheezing
→ Trouble walking or talking.
HELP NOW!
→Heart: pulse is hard to detect; “passing out”
→ Stops playing and cannot start activity again.
*If child has asthma, asthma symptoms may also
→ Lips or fingernails are gray or blue.
need to be treated.
• Emergency Asthma Medications:
•
Emergency Allergy Medications:
Name
Amount
When to Use
Name
Amount
When to Use
1
1
2
2
3
3
4
4
•
Special Instructions:
•
Special Instructions:
__________________________________________________________________
______________________________________________________________________
__________________________________________________________________
______________________________________________________________________
______________________________________________________
_______________________________________________________
_____________________________________________________________
Physician’s Signature
Date
Parent/Guardian’s Signature
Date
Child Care Provider’s Signature
Date
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