SCHOOL ASTHMA PLAN AND MEDICATION ORDERS/504 PLAN _______________________ Date Plan Developed/Revised/Reviewed: ________________________
History of anaphylaxis/severe reaction
____ __ Walk Drive PE/Sports: Day/Time/Period:
BRIEF MEDICAL HISTORY:
Inhaler(s) location: OFFICE BACKPACK ON PERSON
Epi auto-injector(s) location: OFFICE BACKPACK ON PERSON
ALL SECTIONS ON THIS PAGE TO BE COMPLETED BY STUDENT’S LICENSED HEALTHCARE PROVIDER (LHP): ASTHMA TREATMENT INSTRUCTIONS: Asthma / Triggers: None known Animals Cold air Exercise Pollens Respiratory colds Smoke, chemicals, strong odors Other __________________________________________________________________ (i.e., foods, emotions, insects, etc.) USUAL ASTHMA SYMPTOMS: Cough Wheeze Shortness of breath Chest tightness Asking to use inhaler Other _________________ GO ZONE (GREEN) INFREQUENT / MINIMAL SYMPTOMS
Symptoms and/or use of quick relief medication < 2 times a week. (Does not include exercise pre-treatment usage.) Infrequent and minimal symptoms like cough,
Full participation in physical education and sports.
CAUTION ZONE (YELLOW) SIGNIFICANT SYMPTOMS DO NOT LEAVE STUDENT UNATTENDED
If student is using quick relief inhaler > 2 times a week or requires frequent observation by school staff Notify parents+ nurse If student is coughing, wheezing and having dif iculty breathing: Give 2 puffs of quick relief inhaler. May repeat in 10 minutes. Notify parents + nurse if repeated. Other: ____________________________________________________________________________________________________________________________ Until symptoms are in the GO (green) ZONE, restrict strenuous physical activity. If NO improvement after repeated dose, call 911 – See below. STOP ZONE (RED) CALL 911 DO NOT LEAVE STUDENT UNATTENDED
If student is very short of breath, can see ribs during breathing, dif iculty walking to talking, blue appearance to lips or nails, quick relief medication not working.
Give 4 puffs quick relief inhaler (or nebulizer treatment) and notify parents and school nurse. This student needs Epi auto-injector for severe asthma attacks and
Can carry and self-administer Epi auto-injector
Needs help giving the Epi auto-injector.
Other ____________________________________________________________________ EXERCISE PRE-TREATMENT (check all that apply)
Give 2 puffs of quick relief inhaler 15-30 minutes prior to: PE Recess As needed with no less than 2 hours between doses unless student complains of symptoms. May repeat 2 puffs of quick relief inhaler if symptoms occur. Notify parents + nurse if repeated. Quick relief medication orders: (check the appropriate quick relief med(s) ) Uses inhaler with spacer Albuterol 2 puffs (Proair®, Ventolin HFA®, Proventil®) as needed every 4 hours for cough/wheeze Levalbuterol 2 puffs (Xopenex®) as needed every 4 hours for cough/wheeze Other __________________________________________________________________________________ Epi auto-injector : 0.3 mg Jr. 0.15 mg Daily control er meds: _________________________________ Dose _________________________________________ Time ______________ Takes daily controller medications at home
Takes daily controller medications at school
SIDE EFFECTS of medication(s): _______________________________________________________________________________________________________ This student demonstrated correct use of the inhaler in the LHP’s of ice as required. This student is able to carry and use inhalers. YES NO
End date: (not to exceed current school year)
TO BE COMPLETED BY PARENT OR GUARDIAN EMERGENCY CONTACTS Mother/Guardian Father/Guardian
ADDITIONAL EMERGENCY CONTACTS 1.
My student may car y and is trained to self-administer his/her own Epi auto-injector: Yes No Provide extra for office? Yes No My student may car y and use his/her asthma inhaler: Yes
• I understand that the school board or the school district’s employees cannot be held responsible for negative outcomes resulting from self-administration of the inhaled
• This permission to possess and self-administer asthma medication may be revoked by the principal/school nurse if it is determined that the student is not safely and
effectively self-administering the medication.
• A new LHP order/Emergency Care Plan (ECP) for asthma and parent/student agreement for an inhaler/EpiPen must be submit ed each school year. • I understand that if any changes are needed on the ECP, it is the parent’s responsibility to contact the school nurse.
I have reviewed the information on this School Asthma Plan and Medication Orders and request/authorize trained school employees to provide this care and administer the medications in accordance with the Licensed Healthcare Provider’s (LHP’s) instructions. I authorize the exchange of medical information about my child’s asthma between the LHP office and school nurse. Parent/Guardian Signature Student:
• I have demonstrated the correct use of the inhaler to the medical provider and/or school nurse.
• I agree never to share my inhaler with another person or use it in an unsafe manner.
• I agree that if there is no improvement after self-administering, I wil report to an adult at school if the nurse is not available or present.
Student Signature Al school-aged students who use asthma medication(s) at school must have a current School Asthma Plan completed and signed by their health care professional and kept on file in the school of ice (RCW 28A.210.320.370). The form must also be signed by a parent/guardian. The plan must be updated each year and when there are major changes to the plan (such as in medication type or dose). The provider’s office is encouraged to fax the plan to the student’s school nurse. The school plan is intended to strengthen the partnership of families, healthcare providers and the school. It is based on the NHLBI Guidelines for Asthma Management. CARRYING AND ADMINISTERING AND QUICK RELIEF INHALERS: Most students are capable of car ying and using their quick relief inhaler by themselves. The student, student’s parents, school nurse and health care provider should make
this decision. The school nurse should also evaluate technique for effective use.
For District Nurse’s Use Only
Student has demonstrated to the nurse, the skil necessary to use the medication and any device necessary to self-administer the medication
School Nurse Signature
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