Asthma Care Plan Template (2012)
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1
2MUKWONAGO AREA SCHOOL DISTRICT—HEALTH SERVICES
Date Received ____________
DISTRICT NURSE PHONE: 262-363-6292 X27515 FAX: 262-363-6320
Date Revised _____________
Select Year
ASTHMA CARE PLAN for
Student Name:
Routine medications (at home and school)
Date of Birth:
School:
Grade:
Select One
Select One
Transportation:
Bus # ____________
Car
Walk
Preferred Hospital:
Does student have severe allergies?
No
Yes (See Severe Allergic Reaction Care Plan)
Location where Inhaler(s) / Rescue medication(s) is/are stored:
Health Office
Backpack
On Person
Locker # __________
Other __________
Triggers:
Weather (cold air / wind)
Illness
Exercise
Smoke
Dog
Dust
Mold
Pollen
Cat
Other: ____________________________________________________________________________________________________________________
GREEN ZONE:
PRETREATMENT STEPS FOR EXERCISE
(Health Care Provider check all that apply)
Give 2 puffs of rescue medication (name): _______________________
Give 15 minutes before activity as needed (circle indication: Phy Ed class, exercise/ sports, recess) Explanation: _______________________________
Repeat in 4 hours if needed for additional or ongoing physical activity.
YELLOW ZONE:
SICK—UNCONTROLLED ASTHMA
(Health Care Provider complete dosing for rescue inhaler/nebulizer)
IF YOU SEE THIS:
DO THIS:
Difficulty breathing
Stop physical activity
Wheezing
Give rescue medication (name): _____________________________
Frequent cough
1 puff
2 puffs
other: ____________
Via spacer
Complains of chest tightness
If no improvement in 10-15 minutes, repeat use of rescue medication:
Unable to tolerate regular activities but still talking
1 puff
2 puffs
other: ___________
Via spacer
in complete sentences
Student may sip water slowly
Other: ____________________________
Stay with student and help them to maintain a sitting position
Call parent/guardian
Student may resume normal activities once feeling better
If student’s symptoms do not improve or worsen, call 911 and district nurse
If there is no rescue inhaler at school:
Call parent/guardian to pick up student and/or bring inhaler / medication to school.
Inform them that if they cannot get to school, 911 may be called.
RED ZONE:
EMERGENCY SITUATION
(Health Care Provider complete dosing for rescue inhaler/nebulizer)
IF YOU SEE THIS:
DO THIS IMMEDIATELY:
Coughs constantly
Give rescue medication (name): _____________________________
1 puff
2 puffs
other: _____________
Via spacer
Nostrils flaring, struggles or gasps for breath
If no improvement in 10-15 minutes, repeat use of rescue medication:
Stooped over posture
1 puff
2 puffs
other: _____________
Via spacer
Trouble talking (only able to speak 3-5 words)
Call 911 - Inform emergency personal that the reason for the call is asthma
Skin of chest and/or neck pull in with breathing
Call parent/guardian and district nurse
Lips or fingernails are gray or blue
Help student maintain a sitting position
Anxiety or fear
Encourage student to take slower deeper breaths
Confused or decreased level of consciousness
Stay with student and remain calm
Other: _____________________________
ORDERS AND INSTRUCTIONS for RESCUE INHALER / NEBULIZER USE:
(HEALTH CARE PROVIDER: PLEASE CHECK ALL THAT APPLY)
Student understands the proper use of his/her asthma medications, and in my opinion, can carry and use his/her inhaler at school independently.
Student is to notify his/her designated school health staff after using inhaler.
Grades 7—12 may self carry inhaler
Student needs supervision or assistance to use his/her inhaler.
Student has life threatening allergy (See Severe Allergic Reaction Care Plan)
Medication Name:
Possible side effects:
Medication Strength:
Dose:
Frequency:
Additional instructions:
Health Care Provider Signature:
Date:
Phone Number:
Fax:
Page 1 of 2
05/2012 by LAH
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