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Appendixf-3aasthmaactionplan-2

OFFICE OF CATHOLIC SCHOOLS DIOCESE OF ARLINGTON
ASTHMA ACTION PLAN
PROCEDURES ON
REVERSE

TO BE COMPLETED BY PARENT:
S tude nt ________________________________________ DOB _____________ S c hool ___________________________________ Gr a de __________ Em e r ge nc y C onta c t ________________________________________________ R e la tionship _______________________ P hone __________________ Wha t tr igge r s your c hild’ s a sthm a a tta c k: ( C he c k a ll tha t a pply) ________________________________________________ __________________________________________________ De sc r ibe the sym ptom s your c hild e xpe r ie nc e s be f or e or dur ing a n a sthm a e pisode : ( C he c k a ll tha t a pply) TO BE COMPLETED BY LICENSED HEALTH CARE PROVIDER:
The child’s asthma is:
mild persistent
moderate persistent
severe persistent
EXERCISE-INDUCED
Symptoms
Peak Flow
Treatment (For medication administered during school sanctioned
activities,
complete appropriate Inhaler/ Medication
Authorization form)
GREEN ZONE
Controller
> ____________
Relievers
Albuterol (with spacer/nebulizer) 2 puffs 1 minute apart prn 1. Continue daily controller medications
2. Give albuterol 2-4 puffs (one minute between puffs) with spacer or 1 nebulizer treatment, wait 20
If no improvement, repeat 2-4 puffs. Wait 20 minutes. _____ to ______
If no improvement, repeat 2-4 puffs. This will be 3 doses in one hour, proceed to 3 3. If child returns to Green Zone:
Continue to give albuterol 2 puffs every 4 hours for 1 to 2 more days Increase controller to _______________________________________ for next 7 days 4. No physical exercise
If child remains in Yellow Zone for more than 1-2 days or requires albuterol more
than every 4
hours, call your doctor NOW!

Give albuterol (2 puffs with spacer) NOW, and repeat every 20 minutes for 2 more
EMERGENCY!
doses OR give 1
dose nebulized albuterol – Call your doctor
< ____________ Seek emergency care or call 911 if:
Child is struggling to breathe and there is no improvement 20 minutes after taking albuterol Trouble talking or walking Lips or fingernails are gray or blue Chest or neck is pulling in with breathing Student is able to perform procedure alone and may carry Student is able to perform procedure with supervision the inhaler with them, consult school nurse for local protocol Student requires a staff member to perform procedure More than 2 absences related to asthma per month Albuterol is being used as a rescue medication 2 times per week at school The child is persistently in the Yellow Zone ___________________________________________ I approve this Asthma Action Plan for my child. I give my permission for school personnel to follow this plan, release the information contained in this management plan to all adults who have custodial care of my child and who may need to know this information to maintain my child’s health and safety and contact my physician if necessary. I assume full responsibility for providing the school with prescribed medication and delivery/monitoring devices. _______________________________________ Adapted from: Virginia Department of Health, Virginia Department of Education. (2004) Guidelines for Specialized Health Care Pro OFFICE OF CATHOLIC SCHOOLS DIOCESE OF ARLINGTON
ASTHMA ACTION PLAN
TO BE COMPLETED BY PRINCIPAL OR REGISTERED NURSE
S tude nt _______________________________________________ S c hool ___________________________ Te a c he r /Gr a de ____________ P a r e nt/C a r e give r ________________________________ P hone ( H) _______________ P hone ( W) ________________ P hone ( C e ll) ______________
Physician _____________________________________________________________
Office phone number
ASTHMA ACTION PLAN CHECK LIST FOR SCHOOL PERSONNEL
• Asthma Action Plan Part I and II, complete • Medication maintained in school designated area _____________________ _____________________ • Staff trained in medication administration • Copies of plan provided to: Educational yes
After school yes
Food service yes
IMMEDIATE ACTION FOR SYMPTOMS
IF YOU SEE THIS:
5. Allow student to rest 6. If no improvement in 15 minutes, repeat IF YOU SEE THIS
DO THIS IMMEDIATELY
Stooped over posture Trouble walking or talking Lips or fingernails are gray or blue
Full Asthma Action Plan has been implemented.
_____________________________________
Adapted from: Virginia Department of Health, Virginia Department of Education. (2004) Guidelines for Specialized Health Care Procedures

Source: http://www.stwillschool.org/assetsNew/pdfs/APPENDIXF3AAsthmaActionPlan2.pdf

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