Keller Asthma Emergency Action Plan
Download a blank fillable Keller Asthma Emergency Action Plan in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Keller Asthma Emergency Action Plan with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2ASTHMA Emergency Action Plan
Keller ISD Health Services Department
Name: _____________________ DOB: __________ Teacher/Grade:_________
Emergency Contact #1:______________________ Preferred Contact Number: _________________
Emergency Contact#2: ______________________ Preferred Contact Number: _________________
Physician for Asthma: ______________________ Phone Number: ___________________________
Preferred Hospital: _________________________
CHECK IF APPLICABLE
Signs and Symptoms
Triggers
What helps your child during an Asthma attack?
Wheezing
Exercise
Markers
Loosen Clothing
Difficulty breathing
Cold Air
Perfume
Administer Medication
Chest tightness
Dust
Smoke
Rest/Relaxation
Cough
Stress
Animals
Breathing exercises
Other:
Other:
Other:
_____________________________
____________________________
________________________________
_____________________________
____________________________
________________________________
_____________________________
____________________________
________________________________
Will student require peak flow monitoring?
Yes
No
What is the personal best peak flow number? ________________________________________________________
Times peak flow should be checked during school: __________________________________________________
Please list medications to be administered at school for asthma: (Medication Authorization form required)
____________________________
_____________________________
______________________________
Will student need a nebulizer at school?
Yes
No * If yes, a Special Procedure form will need to be
completed by parent/physician.
Will student carry an inhaler during the school day?
Yes
No *If yes, a separate form must be completed
by parent/physician. An extra inhaler should be kept in school clinic.
STEPS TO TAKE DURING AN ASTHMATIC EPISODE:
1.
Administer authorized medication as directed
2.
Monitor student
3.
SEEK EMERGENCY MEDICAL CARE IF STUDENT EXPERIENCES ANY OF THE
FOLLOWING:
•
No improvement 15-20 minutes after initial treatment with medication and a relative cannot be
reached.
•
Student exhibits any of the following:
Chest and neck pulled in when breathing. Hunched over while breathing. Struggling to
breath. Trouble walking or talking. Lips or fingernails turn gray.
Parent Signature: _________________________________________ Date: ____________________________
Registered Nurse Signature: ________________________________ Date: ____________________________
Licensed Vocational Nurse Signature: ________________________ Date:____________________________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business