Kansas Asthma Action Plan
Student Name: ______________________________________ Date of Birth____/____/____
Grade: _______________
THE ABOVE STUDENT IS DIAGNOSED WITH ASTHMA. THIS FORM WILL ASSIST IN THE MANAGEMENT OF HIS/HER ASTHMA.
PLEASE PLACE THIS FORM IN THE STUDENT'S MEDICAL FILE
Parent/Guardian Name: _______________________________ Number where can be reached: (____) ______‐_____________
Student’s Primary Care Provider: ______________________________________
Phone: (____) ______‐_____________
Daily Medication Plan
This is the student’s daily
Medicine/Dose
When to Give it
medicine plan:
Albuterol/Xopenex inhaler 2 sprays
OR Every 4‐6 hours as needed for wheezing/c
ough
•
The student has no
A
lbuterol/Xopenex solution 1 dosa
ge
asthma symptoms.
______________________________
________________________________
______
•
The student can do
______________________________
_______________________________
_______
usual activities.
A
lbuterol/Xopenex inhaler 2 sprays
OR nebulizer treatment 15‐20 minutes before
•
The student can sleep
exercise, only if needed
without symptoms.
Asthma Emergency Plan‐What to do for increased asthma symptoms
Have the student take Albuterol inhaler 2 sprays OR
Trigger List:
one nebulizer treatment every 20 minutes up to 3
Do this first when asthma
Chalk Dust
times. This is a test dose to see if the student’s asthma
symptoms occur:
Cigarette Sm
oke
improves with Albuterol.
Colds/Flu
Dust or dust
What to do Next:
When to Do it:
mites
Stuffed an
imals
Have the student return to
Good Response to Test Dose of Albuterol
•
Carpe
t
The student’s symptoms improve after 1‐2 treatments.
the classroom.
•
Exercise
The student no longer has symptoms (wheezing, coughing,
Notify parents of students
Mold
shortness of breath, chest tightness.)
need for a quick relief
•
Ozon e
alert days
Student may continue Albuterol/Xopenex every 4 hours for
medicine.
24‐48 hours.
Pests
Pets
Contact the parent or
Incomplete Response to Test Dose of Albuterol
Plants, flowers
,
•
The student is experiencing mild to moderate symptoms
guardian.
cut grass, polle
n
(wheezing, coughing shortness of breath, chest tightness)
Strong odors,
Contact the PCP for step‐up
after taking 3 treatments.
perfume,
medicine.
•
The student cannot do normal school activities.
cleaning
________________________
products
Poor Response to Test Dose of Albuterol
Seek emergency medical
Sudden
•
The student does not feel better 20‐30 minutes after
temperature
care in most locations, call
taking the Albuterol.
change
911.
•
The student has severe symptoms (coughing; extreme
Wood smoke
Call the PCP _____________
shortness of breath; skin reactions between
the ribs or
Foods:
________________________
________
___________
at the neck).
NOTE: Wheezing may be
_________
•
The student has trouble walking or talkin
g.
absent because air cannot
Other:
•
The student’s lips or fingernails are b
lue.
move out of the airways.
______________
•
The student is struggling to breathe.
______________________________________________________________________________________
____/____/____
Signature of Parent/Guardian
Date
______________________________________________________________________________________
____/____/____
Signature of Physician
Date
(Permission Signatures on back)
KS approval 07/15/09