Form Appendix F-3a - Office Of Catholic Schools Diocese Of Arlington Asthma Action Plan - 2010

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Appendix F-3A
OFFICE OF CATHOLIC SCHOOLS DIOCESE OF ARLINGTON
ASTHMA ACTION PLAN
FOR USE WITH INHALER AUTHORIZATION FORM
PROCEDURES ON REVERSE
PART I
TO BE COMPLETED BY PARENT:
Student ________________________________________ DOB _____________ School ___________________________________ Grade __________
Parent / Emergency Contact
Phone number(s)
____________________________________________
1..) ____________________________ 2.) ___________________________
____________________________________
1.) _____________________
2.) ______________________
What triggers your child’s asthma attack: (Check all that apply)
Illness
Cigarette or other smoke
Food ________________________________________________
Emotions
Exercise
Allergies
Cat
Dog
Dust
Mold
Pollen
Weather changes
Chemical odors
Other __________________________________________________
Describe the symptoms your child experiences before or during an asthma episode: (Check all that apply)
Cough
“Tightness” in chest
Rubbing chin/neck
Shortness of breath
Breathing hard/fast
Feeling tired/weak
Wheezing
Runny nose
Other ______________________________
PART II
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,
attach a complete Inhaler/ Medication Authorization form)
• No cough or wheeze
GREEN
Controller
How much
When
• Able to sleep through the
ZONE
Advair
night
WELL
Flovent (with spacer)
• Able to run and play
Pulmicort
• Usual medications control
>
asthma
Singulair
___________
Serevent
Other
Relievers
2 puffs 1 minute apart prn
Albuterol (with spacer/nebulizer)
20 min before exercise
Other
• Increased asthma
1. Continue daily controller medications
YELLOW
symptoms (shortness of
2. Give albuterol 2-4 puffs (one minute between puffs) with spacer or 1 nebulizer treatment, wait 20 min.
ZONE
breath, cough, chest pain)
If no improvement, repeat 2-4 puffs. Wait 20 minutes.
SICK
• Wakes at night due to
If no improvement, repeat 2-4 puffs. This will be 3 doses in one hour, proceed to 3
asthma
3. If child returns to Green Zone:
_____ to
• Unable to do usual
Continue to give albuterol 2 puffs every 4 hours for 1 to 2 more days
_____
activities
Increase controller to _______________________________________ for next 7 days
• Needs reliever medications
4.
No physical exercise
Physical exercise as tolerated
more often
If child remains in Yellow Zone for more than 1-2 days or requires albuterol more than every 4
hours, call your doctor NOW!
• Very short of breath,
Give albuterol (2 puffs with spacer) NOW, and repeat every 20 minutes for 2 more doses OR give 1
RED ZONE
difficulty breathing
dose nebulized albuterol – Call your doctor
EMERGENC
• Constant cough
Seek emergency care or call 911 if:
Y!
• Reliever medications do not
Child is struggling to breathe and there is no improvement 20 minutes after taking albuterol
help
Trouble talking or walking
<
Lips or fingernails are gray or blue
___________
Chest or neck is pulling in with breathing
For inhaled medications:
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
Notify health care provider if:
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
___________________________________________
______________________
_____________________
Licensed Health Care Provider Signature
Date
Phone
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.
_______________________________________
_____________________
Parent Signature
Date
Adapted from: Virginia Department of Health, Virginia Department of Education. (2004) Guidelines for Specialized Health Care Pro
2010

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