Plano Independent School District Asthma Action Plan Page 2
ADVERTISEMENT
1
2ASTHMA ACTION PLAN continued
DAILY TREATMENT PLAN AND EMERGENCY PLAN
Please list any medication taken daily to manage asthma, including nebulizer treatments:
Name
Purpose
Dosage
When to use
1. __________________
________________
______________
_______________
2. __________________
________________
______________
_______________
3. __________________
________________
______________
_______________
Medical Equipment:
Please list any medical equipment this student will need to treat his/her asthma at school
(i.e. spacer, nebulizer, oxygen, etc.). Parent will provide equipment needed.
__________________________________________________________________________
BEST PEAK FLOW _______________
Treatment if peak flow in Green Zone (peak flow between 80-100% of personal best):
__________________________________________________________________________
__________________________________________________________________________
Treatment if peak flow in Yellow Zone (peak flow between 50-80% of personal best):
__________________________________________________________________________
__________________________________________________________________________
Treatment if peak flow in Red Zone (peak flow less than 50% of personal best):
__________________________________________________________________________
__________________________________________________________________________
Emergency action is necessary when this student has symptoms such as:
1. _____________________________________
3. _____________________________________
2. _____________________________________
4. _____________________________________
Seek emergency medical care if this student experiences any of the following:
a. No improvement 15-20 minutes after initial treatment with medication and a relative cannot be
reached.
b. Student exhibits: Chest and neck pulled in with breathing, hunched over while breathing,
struggling to breathe, trouble walking or talking, stops playing and cannot start activity again, or
lips or fingernails turn gray or blue.
Comments and special instructions:
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Physician’s Signature
Phone
Date
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
I give permission to my child's school to administer daily and emergency medications as necessary, in
accordance with physician's instructions above.
Parent/Guardian’s Signature _____________________________ Date
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business