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Microsoft word - appendix f-3a asthma action plan .doc


Student ________________________________________ DOB _____________ School ___________________________________ Grade __________
Emergency Contact ________________________________________________ Relationship _______________________ Phone __________________

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)
The child’s asthma is:
mild persistent
moderate persistent
severe persistent
Peak Flow
Treatment (For medication administered during school sanctioned activities,
complete appropriate Inhaler/ Medication Authorization form)
> ____________
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. _____ 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 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 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

Student _______________________________________________ School ___________________________ Teacher/Grade ____________
________________________________ Phone (H) _______________ Phone (W) ________________ Phone (Cell) ______________
Physician _____________________________________________________________ Office phone number ___________________________
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
5. Allow student to rest 6. If no improvement in 15 minutes, repeat IF YOU SEE THIS
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 OFFICE OF CATHOLIC SCHOOLS DIOCESE OF ARLINGTON
I hereby request designated school personnel to administer an inhaler as directed by this authorization. I agree to release, indemnify, and hold harmless the designated school personnel, or agents from lawsuits, claim expense, demand or action, etc., against them for helping this student use an inhaler, provided the designated school personnel comply with the Licensed Healthcare Provider (LHCP) or parent or guardian orders set forth in accordance with the provision of part II below. I have read the procedures outlined on the back of this form and assume responsibility as required □ New (If new, the first full dose must be given at home to assure that the student does not have a negative No LPN or clinic room aide shall administer inhaler or treatment, unless the principal has reviewed all the required clearances. _____________________________________________ __________________________________________ ______________________ TO BE COMPLETED BY LICENSED HEALTH CARE PROVIDER (LAY LANGUAGE, NO ABBREVIATIONS)
If the student is taking more than one medication at school, list sequence in which inhalers are to be taken Start: End: Check 9 the appropriate boxes: □ I believe that this student has received information on how and when to use an inhaler and that he or she demonstrates its proper use. □ The student is to carry an inhaler during school and during sanctioned events with principal approval. (An additional inhaler, to be used as backup, WILL BE kept in the clinic or other approved school location.) □ It is not necessary for the student to carry his inhaler during school, the inhaler will be kept in the clinic or other approved school location. □ Asthma Action Plan is attached ___________________________________ _______________________________ ___________________ ______________ Licensed Health Care Provider (Signature) ___________________________________ _______________________________ ___________________ ______________ ___________________________________________________ Student Signature (Required if student carries inhaler) PART III TO BE COMPLETED BY PRINCIPAL OR REGISTERED NURSE
□ Parts I and II above are completed including signatures. (It is acceptable if all items in part II are written on the LHCP stationery or a prescription pad.) □ Inhaler is appropriately labeled. _________________ Date by which any unused inhaler is to be collected by the parent (within one week after expiration of the physician order or on the last day of school). □ I have reviewed the proper use of the inhaler with the student and agree/disagree that student should self carry in school. _____________________________________________ _______________________________ PARENT INFORMATION ABOUT MEDICATION PROCEDURES
1. In no case may any health, school, or staff member administer any medication outside the framework of
the procedures outlined here in the Office of Catholic Schools Policies and Guidelines and Virginia School
Health Guidelines
2. Schools do NOT provide medications for student use.
3. Medications should be taken at home whenever possible. The first dose of any new medication must be given at
home to ensure the student does not have a negative reaction. 4. Medication forms are required for each Prescription and Over The Counter (OTC) medication administered in 5. All medication taken in school must have a parent/guardian signed authorization. Prescription medications,
herbals and OTC medications taken for 4 or more consecutive days also require a licensed healthcare provider’s
(LHCP) written order. No medication will be accepted by school personnel without the accompanying
complete and appropriate medication authorization form
6. The parent or guardian must transport medications to and from school.
7. Medication must be kept in the school health office, or other principal approved location, during the school day.
All medication will be stored in a locked cabinet or refrigerator, within a locked area, accessible only to authorized personnel, unless the student has prior written approval to self-carry a medication (inhaler, Epi-pen). If the student self carries, it is advised that a backup medication be kept in the clinic. 8. Parents/guardians are responsible for submitting a new medication authorization form to the school at the start of the school year and each time there is a change in the dosage or the time of medication administration. 9. A Licensed Health Care Provider (LHCP) may use office stationery, prescription pad or other appropriate documentation in lieu of completing Part II. The following information written in lay language with no abbreviations must be included and attached to this medication administration form. Signed faxes are acceptable. a. Student name b. Date of Birth c. Diagnosis d. Signs or symptoms e. Name of medication to be given in school f. Exact dosage to be taken in school g. Route of medication h. Time and frequency to give medications, as well as exact time interval for additional dosages. i. Sequence in which two or more medications are to be administered j. Common side effects k. Duration of medication order or effective start and end dates l. LHCP’s name, signature and telephone number m. Date of order 10. All prescription medications, including physician’s samples, must be in their original containers and labeled by a LHCP or pharmacist. Medication must not exceed its expiration date. 11. All Over the Counter (OTC) medication must be in the original, small, sealed container with the name of the medication and it’s expiration date clearly visible. Parents/guardians must label the original container of the OTC with: a. Name of student b. Exact dosage to be taken in school c. Frequency or time interval dosage is to be administered 12. The student is to come to the clinic or a predetermined location at the prescribed time to receive medication. Parents must develop a plan with the student to ensure compliance. Medication will be given no more than one half hour before or after the prescribed time. 13. Students are NOT permitted to self medicate. The school does not assume responsibility for medication
taken independently by the student. Exceptions may be made on a case-by-case basis for students who
demonstrate the capability to self-administer emergency life saving medications (e.g. inhaler, Epi-pen)
14. Within one week after expiration of the effective date on the order, or on the last day of school, the parent or guardian must personally collect any unused portion of the medication. Medications not claimed within that period will be destroyed.

Source: http://ourladyofhopeschool.net/download/nurse/Asthma%20Action%20Plan.pdf

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