Virginia Asthma Action Plan School Division: ________________________________________________________________________ Name

Date of Birth

Effective Dates / / to

Health Care Provider

Provider’s Phone

Parent/Guardian

Parent/Guardian Phone

Parent/Guardian Email:

Additional Emergency Contact

Contact Phone

Contact Email:

Asthma Severity

Asthma Triggers (Things that make your asthma worse)

/

/

GREEN means Go! Use CONTROL medicine daily

YELLOW means Caution! Add RESCUE medicine

RED means DANGER! Get help from a doctor now!

□ Intermittent Persistent:

or



Mild





Severe

Green Zone:

Moderate

□ Colds □ Smoke (tobacco, incense) □ Pollen □ Dust □ Animals:_________ □ Strong odors □ Mold/moisture □ Pests (rodents, cockroaches) □ Stress/Emotions □Exercise □Gastroesophageal reflux □ Season (circle):Fall, Winter, Spring, Summer □ Other:_____________________________________

Last Flu

Pneumonia

Shot:

Shot:

/

/

/ /

Go! — Take these CONTROL (PREVENTION) Medicines EVERY Day

You have ALL of these: Breathing is easy No cough or wheeze

 No control medicines required. Always rinse mouth after using your daily inhaled medicine.  ___________________________________, ____ puff (s) MDI with Spacer __ times a day Inhaled Corticosteroid or Inhaled corticosteroid/long-acting -agonist

 _____________________________________, ____ nebulizer treatment (s) __ times a day Inhaled Corticosteroid

Can work and play Can sleep all night

 ___________________________________, take ____ by mouth once daily at bedtime Leukotriene antagonist

Peak flow in this area: ______ to ______ (More than 80% of Personal Best) Personal best peak flow:________

For asthma with exercise, ADD:

 __________________________, _____ puffs with spacer 15 minutes before exercise Fast acting Inhaled -agonist

For nasal/environmental allergy, ADD:

 ____________________________, use _____ spray (s) per nostril _____ times a day Nasal corticosteroid

Yellow Zone: Caution! — Continue CONTROL Medicines and ADD RESCUE Medicines You have ANY of these: First sign of a cold Cough or mild wheeze Tight chest Problems sleeping, working, or playing Peak flow in this area: ______ to _____

 _________________, ____ puffs with spacer every ____ hours as needed Inhaled b-agonist

 _________________, ____ nebulizer treatment (s) every ____ hours as needed Inhaled b-agonist

 Other ________________________________________________________ Call your Healthcare Provider if you need rescue medicine for more than 24 hours or two times a week, or if your rescue medicine doesn’t work

(60%-80% of Personal Best)

Red Zone:

DANGER! — Continue CONTROL & RESCUE Medicines and GET HELP!

You have ANY of these: Can’t talk, eat, or walk well Medicine is not helping Breathing hard and fast Blue lips and fingernails Tired or lethargic Ribs show

Peak flow in this area: _____ to _____

 ________________, __ puffs with spacer every 15 minutes, for THREE treatments Inhaled -agonist

 ________________, __ nebulizer treatment every 15 minutes, for THREE treatments Inhaled -agonist

Call your doctor while administering the treatments.

 Other

IF YOU CANNOT CONTACT YOUR DOCTOR: Call 911 for an ambulance, or go directly to the Emergency Department!

(Less than 60% of Personal Best) SCHOOL MEDICATION CONSENT AND HEALTH CARE PROVIDER ORDER FOR CHILDREN/YOUTH

CHECK ____

ALL THAT APPLY: Student has been instructed in the proper use of all of his/her asthma medications, and in my opinion, CAN CARRY AND SELF-ADMINISTER HIS or HER INHALER AT SCHOOL.

____

Student is to notify his/her designated school health officials after using inhaler at school.

____

Student needs supervision or assistance to use his/her inhaler.

____

Student should NOT carry his/her inhaler while at school.

MD/NP/PA

SIGNATURE: ____________________________ DATE_____

REQUIRED SIGNATURES: I give permission for school personnel to follow this plan, administer medication and care for my child and contact my provider if necessary. I assume full responsibility for providing the school with prescribed medication and delivery/ monitoring devices. I approve this Asthma Management Plan for my child. PARENT/GUARDIAN ________________________

Date _____

SCHOOL NURSE/DESIGNEE ___________________

Date _____

OTHER _________________________________

Date _____

Virginia Asthma Action Plan approved by the Virginia Asthma Coalition (VAC) 4/11 Based on NAEPP Guidelines and modified with permission from the D.C. Asthma Action Plan via District of Columbia Department of Health, DC Control Asthma Now, and District of Columbia Asthma Partnership Blank copies of this form may be reproduced or downloaded from www.virginiaasthma.org

Asthma Action Plan - The Steward School

(Less than 60% of Personal Best). □ ... Parent/Guardian Email: Additional ... Call your Healthcare Provider if you need rescue medicine for more than 24.

205KB Sizes 5 Downloads 210 Views

Recommend Documents

Asthma Action Plan - The Steward School
(60%-80% of Personal Best). You have ANY of these: Can't talk, eat, or walk well. Medicine is not helping. Breathing hard and fast. Blue lips and fingernails.

Asthma Action Plan-Dr. form.pdf
Call your Health-Care Provider ... NORTH DAKOTA DEPARTMENT OF HEALTH ... Emergency Medication Possession and Self-Administration Approval.

asthma-action-plan-aafa.pdf
Retrying... Download. Connect more apps... Try one of the apps below to open or edit this item. asthma-action-plan-aafa.pdf. asthma-action-plan-aafa.pdf. Open.

Asthma Action Plan.pdf
Page 1 of 2. May. Page 1 of 2. Page 2 of 2. best. 2-3. Page 2 of 2. Asthma Action Plan.pdf. Asthma Action Plan.pdf. Open. Extract. Open with. Sign In. Main menu.

Sidney Lanier ES FExpressive Arts Vanguard School Action Plan ...
Sidney Lanier ES FExpressive Arts Vanguard School Action Plan 2013-2014.pdf. Sidney Lanier ES FExpressive Arts Vanguard School Action Plan 2013-2014.

The Steward Leader - Tim Keller.pdf
Page 1. Whoops! There was a problem loading more pages. Retrying... The Steward Leader - Tim Keller.pdf. The Steward Leader - Tim Keller.pdf. Open. Extract.

THE EFFECT OF BRONCHIAL ASTHMA ATTACK AND ANTI-ASTHMA ...
medications are delivered through inhalation to their main site of action .... insulin resistance with the incidence of asthma-like symptoms in adults. [18].

The Steward Leader - Tim Keller.pdf
There was a problem previewing this document. Retrying... Download. Connect more apps... Try one of the apps below to open or edit this item. The Steward Leader - Tim Keller.pdf. The Steward Leader - Tim Keller.pdf. Open. Extract. Open with. Sign In.

Establishment Action Plan Puppetry Development Consortium 11.3 ...
Establishment Action Plan Puppetry Development Consortium 11.3.pdf. Establishment Action Plan Puppetry Development Consortium 11.3.pdf. Open. Extract.