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
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
Remarques • Les différentes parties du problème sont indépendantes ;• Lors de l’écriture de mécanismes, il n’est pas nécessaire d’écrire les molécules dans leurintégralité ; seul le fragment utile pour expliquer la réaction sera représenté. Lorsqu’on vousdemande d’identifier une structure, il faudra par contre la dessiner complètement ;• Toute réponse doit ê