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STUDENT ASTHMA/ANAPHYLAXIS ACTION PLAN

STUDENT NAME: DATE OF BIRTH:
/ /
(MONTH) (DAY) (YEAR)
EXERCISE PRE-TREATMENT: Administer inhaler (2 inhalations) 15-30 minutes prior to exercise. (e.g., PE, recess, etc).
 Albuterol HFA inhaler (Proventil, Ventolin, ProAir)  Use inhaler with spacer/valved holding chamber  Levalbuterol (Xopenex HFA)  May carry & self-administer inhaler (MDI)  Pirbuterol inhaler (Maxair)  Other: ASTHMA TREATMENT
ANAPHYLAXIS TREATMENT
Give quick relief medication when student experiences
Give epinephrine when student experiences allergy
asthma symptoms, such as coughing, wheezing or tight chest. symptoms, such as hives, difficulty breathing (chest or neck “sucking in”), lips or fingernails turning blue, or  Albuterol HFA (Proventil, Ventolin, ProAir) 2 inhalations  Levalbuterol (Xopenex HFA) 2 inhalations  Use inhaler with spacer/valved holding chamber  May carry & self-administer inhaler (MDI)  Albuterol inhaled by nebulizer (Proventil, Ventolin,
 .63 mg/3 mL  1.25 mg/3 mL  2.5 mg/3 ml  Adrenaclick® 0.3 mg  Adrenaclick® 0.15 mg  Levalbuterol inhaled by nebulizer (Xopenex)
 0.31 mg/3 mL  0.63 mg/3 mL  1.25 mg/3 mL  Other:  May carry & self-administer epinephrine CLOSELY OBSERVE THE STUDENT AFTER
CALL 911 AFTER GIVING EPINEPHRINE &
GIVING QUICK RELIEF MEDICATION
CLOSELY OBSERVE THE STUDENT
If after 10 minutes:
EVEN if student improves, the student
 Symptoms are improved, student may return to should be observed for recurrent
classroom after notifying parent/guardian symptoms of anaphylaxis in an emergency
 No improvement in symptoms, repeat the treatment medical facility
If student does not improve or continues
If student continues to worsen, CALL 911 and
to worsen, INITIATE the Nebraska
INITIATE the Nebraska Schools’ Emergency
Schools’ Emergency Response to Life-
Response to Life-Threatening Asthma or
Threatening Asthma or Systemic Allergic
Systemic Allergic Reactions (Anaphylaxis)
Reactions (Anaphylaxis) Protocol
Protocol
 This student has a medical history of asthma and/or anaphylaxis and I have reviewed the use of the above-listed medication(s). If medications are self-administered, the school staff MUST be notified.

Additional information (i.e. asthma triggers, allergens)
Physician name (please print) Phone
Physician signature Date
Parent si

gnature Date

Reviewed by school nurse/nurse designee Date
Version: 10/10
STUDENT ASTHMA/ALLERGY/ANAPHYLAXIS INFORMATION
(THIS PAGE TO BE COMPLETED BY PARENT/GUARDIAN)
STUDENT NAME: AGE: GRADE:
SCHOOL: HOMEROOM TEACHER:
PARENT/GUARDIAN: PHONE(H) (W)
PARENT/GUARDIAN: PHONE(H) (W)
ALTERNATE EMERGENCY CONTACT: PHONE(H) (W)
KNOWN ASTHMA TRIGGERS: Please check the boxes to identify what can cause an asthma episode for your student.
 Exercise  Respiratory/viral infections  Odors/fumes/smoke  Mold/mildew  Pollens  Animals/dander  Dust/dust mites  Grasses/trees  Temperature/weather—humidity, cold air, etc. KNOWN ALLERGY/INTOLERANCE: Please check those which apply and describe what happens when your child eats or
comes into contact with the allergen.
Peanuts  Tree Nuts  Fish/shellfish
NOTICE: If your child has been been prescribed epinephrine (e.g. EpiPen) for an allergy, it is also necessary to provide epinephrine at
school. If your student requires a special diet to limit or eliminate foods, your school may ask your physician to complete the form “Medical Statement for Students Requiring Special Meals”. DAILY MEDICATIONS: Please list daily medications used at home and/or to be administered at school.
Medication Name
Amount/Dose
When administered
I understand that all medications to be administered at school must be provided by the parent/guardian.

Parent signature: Date:

Reviewed by school nurse/nurse designee: Date:
Version: 10/10

Source: http://we.springfieldplatteview.org/modules/groups/homepagefiles/cms/953382/File/Forms/asthma%20action%20plan%202012-2013.pdf

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