Microsoft word - maine school action plan.doc

MAINE SCHOOL ASTHMA PLAN
Child Name:
To be completed by parent or school:
Teacher:_____________________ Rm #:____ To be completed by parent:
I authorize release of my child’s medical records and asthma plans from my child’s physician’s office to the school nurse.
Parent or Guardian signature: _____________________________________________ Date:__________ Parent or Guardian tel.# / pager #: _________________________________________ To be completed by physician:
Physician name: ____________________________________________ Tel.#: ___________________________
Peak Flow
Child’s predicted, or personal best peak flow: _______ Green zone: _________ Yellow zone: __________ Red zone:_______ Medications
Preventive (Controller) meds:
_______________________________________________________________ _______________________________________________________________ _______________________________________________________________ Rescue inhaler/ nebulizer (check the appropriate rescue med, circle device, list dose/ frequency):
Albuterol (Proventil, Ventolin) inhaler with spacer or nebulizer ___________________________________
Maxair inhaler ________________________________________________________________________
Other inhaler with spacer or nebulizer _____________________________________________________
Allergies /Triggers for asthma: OR None known
Other triggers to avoid____________________________________________________________________________ ____________________________________________________________________________ Child has history of severe food allergy: _______________________________________________________________ Exercise Pretreatment Instructions
Give 2 puffs of rescue inhaler 15 minutes prior to recess/ gym, and/ or ______________________________________ May repeat 2 puffs of rescue inhaler if symptoms recur with exercise. Measure Peak Flow prior to recess / gym; restrict aerobic activity when child’s peak flow is below _______. Asthma Exacerbation Treatment Instructions
YELLOW ZONE: If child is coughing, wheezing or short of breath, and/or peak flow is in yellow zone:
Give 2 puffs of child’s rescue inhaler with spacer. May be repeated in 10 minutes if doesn’t recover to green zone. Other_____________________________________________________________________________________ RED ZONE: If child is in respiratory distress, and/or peak flow is in red zone:
Give 4 puffs rescue inhaler (or nebulizer treatment of albuterol), and call parent and physician; Call 911 if child does not improve quickly or parents/physician cannot be reached.
Other: __________________________________________________________________ Special Instructions
Student may carry and use his/her inhaled medicines him/herself after demonstrating appropriate use of inhaler to school nurse Contact physician and parent if student is using rescue medicines more than 2X/ week (i.e. in excess of normal pre-exercise treatment) Other: ____________________________________________________________________________________________
____________________________________________________________________________________________
___________________________________________ _________
Physician signature Date
For additional copies of this form, call Maine Lung Association at 1-800-499-LUNG For additional copies of this form, call Maine Lung Association at 1-800-499-LUNG

Source: http://staff.highschool.spsd.org/nurse/resources/Forms/MaineSchoolAsthmaPlan.pdf