Form Appendix F-3a - Office Of Catholic Schools Diocese Of Arlington Asthma Action Plan - 2010 Page 2
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2Appendix F- 3A
OFFICE OF CATHOLIC SCHOOLS DIOCESE OF ARLINGTON
ASTHMA ACTION PLAN
PAGE 2
PART III
TO BE COMPLETED BY PRINCIPAL OR REGISTERED NURSE
Student _______________________________________________ School ___________________________
Teacher/Grade ____________
Physician _____________________________________________________________
Office phone number ___________________________
ASTHMA ACTION PLAN CHECK LIST FOR SCHOOL PERSONNEL
• Asthma Action Plan Part I and II complete
yes
no
• Medication authorization complete
yes
no
n/a
• Inhaler authorization complete
yes
no
n/a
• Medication maintained in school designated area
yes
no
• Medication self carried
yes
no
• Expiration date of medication (s)
_____________________
_____________________
• Staff trained in medication administration
yes
no
• Copies of plan provided to:
Educational
yes
no
n/a
After school yes
no
n/a
Athletic
yes
no
n/a
Food service yes
no
n/a
IMMEDIATE ACTION FOR SYMPTOMS
IF YOU SEE THIS:
DO THIS:
Complains of chest tightness
1. Stop activity
Coughing
2. Give one puff of rescue inhaler
Difficulty breathing
3. Wait at least 1 minute
Wheezing
4. Give second puff of rescue inhaler
5. Allow student to rest
6. If no improvement in 15 minutes, repeat steps 2-
4
7. If symptoms worsen call 911 and
parents/emergency contact
IF YOU SEE THIS
DO THIS IMMEDIATELY
Coughs constantly
1. Call 911
Struggles or gasps for breath
2. Give rescue medication
Chest and neck pull in with breathing
3. Call parents/emergency contact
Stooped over posture
Trouble walking or talking
Lips or fingernails are gray or blue
Full Asthma Action Plan has been implemented.
_____________________________________
_____________________________
Principal or Registered Nurse
Date
Adapted from: Virginia Department of Health, Virginia Department of Education. (2004) Guidelines for Specialized Health Care Procedures
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