ASTHMA

Student: 	Grade: 		_	School Contact: 	DOB: 	_
Asthma Triggers: 			Best Peak Flow: 		_ Mother: 	lv!Home #: 	MWork #: 		MCell #: 	_ Father: 	FHome #: 	F\v'ork #: 		FCell #: 		_ Emergency Contact: 		Relationship: 		Phone: 	_

Student Photo

SYMPTOMS OF AN ASTHMA EPISODE MAY INCLUDE ANY/ALL OF THESE:
CHANGES IN BREATHING: coughing, wheezing, breathing through mouth,
shortness of breath, Peak Flow of< 	.
VERBAL REPORTS of: chest tightness, chest pain, cannot catch breath,
dry mouth, "neck feels funny", doesn't feel well, speaks quietly.
APPEARS: anxious, sweating, nauseous, fatigued, stands with shoulders hunched
over and cannot straighten up easily.

SIGNS OF AN ASTHMA EMERGENCY:
Breathing with chest and/or neck pulled in, sits hunched over, nose opens wide
when inhaling. Difficulty in walking and talking.
Blue-gray discoloration of lips and/or fingernails.
Failure of medication to reduce worsening symptoms with no irnprovement 15 - 20 minutes after initial treatment.
Peak Flow of 	or below.
^Respirations ^greater ^than ^30/minute.
Pulse greater than 120/minute.

STAFF MEMBERS INSTRUCTED:
0 Administration

D Classroom Teacher(s)
D Support Staff

D Special Area Teacher(s)
D Transportation Staff

TREATMENT:
Stop activity immediately.
Help student assume a c01nfortable position. Sitting up is usually more comfortable.
Encourage purse-lipped breathing.
Encourage fluids to decrease thickness of lung secretions.
Give medication as ordered: 	_
Observe for relief of symptoms. ^If ^no ^relief ^noted ^in ^15 ^- ^20 ^minutes, ^follow ^steps ^below ^for ^an ^asthma ^etnergency.
Notify school nurse at	^whowill ^call ^parents/guardian ^and ^healthcare ^provid_e_r.	^_

STEPS TO FOLLOW FOR AN ASTHMA EMERGENCY:
Call 911 (Emergency Medical Services) and inform the that you have an asthma emergency. They will ask the student's age, physical symptoms, and what medications he/she has taken and usually takes.
•A staff member should accompany the student to the emergency room if the parent, guardian or emergency contact is not present and adequate supe1·vision for other students is present. Preferred Hos_pital if transported:

Healthcare Provider: 	Phone: 	_
\'(fritten by: 	^Date: 	^_
D Copy provided to Parent	^D ^Copy ^sent ^to ^Healthcare ^Provider
Parent/Guardian Signature to share this plan with Provider and School Staff: 	_
This pla11 is i11 effect far the t11m11t schoolyear a11d s111m11er school as 11eeded.	^Revised ^1/ ^08