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Microsoft word - f3a.doc

OFFICE OF CATHOLIC SCHOOLS DIOCESE OF ARLINGTON
ASTHMA ACTION PLAN
FOR USE WITH INHALER AUTHORIZATION FORM
PROCEDURES ON REVERSE
TO BE COMPLETED BY PARENT:

Student ________________________________________ DOB _____________ School ___________________________________ Grade __________
Parent
Emergency
Contact Phone
number(s)
____________________________________________ 1.) ____________________________ 2.) ___________________________ ____________________________________
What triggers your child’s asthma attack: (Check all that apply)
Food ________________________________________________ Other __________________________________________________ Describe the symptoms your child experiences before or during an asthma episode: (Check all that apply)
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,
attach a complete Inhaler/ Medication Authorization form)
Controller
Relievers
1. Continue daily controller medications
2. Give albuterol 2-4 puffs (one minute between puffs) with spacer or 1 nebulizer treatment, wait 20 min.
If no improvement, repeat 2-4 puffs. Wait 20 minutes. 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 doses OR give 1
EMERGENC
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 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

Student _______________________________________________ School ___________________________ Teacher/Grade ____________

Physician _____________________________________________________________ Office phone number ___________________________
ASTHMA ACTION PLAN CHECK LIST FOR SCHOOL PERSONNEL
complete yes
 Medication maintained in school designated area carried yes
 Copies of plan provided to: Educational yes no n/a
yes no n/a
yes no n/a
yes no n/a
IMMEDIATE ACTION FOR SYMPTOMS
IF YOU SEE THIS:
5. Allow student to rest 6. If no improvement in 15 minutes, repeat steps 2- 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.blessedsacramentcc.org/school/Current/DownloadableForms/DocsAndForms/Handbooks/f3ainPDF.pdf

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