Individualized Emergency Medical Plan (Iemp)

Asthma Emergency Care Plan/504 PLAN

Name: Birth date: Teacher: Grade: Parent/Guardian: Address: Home Phone: Work Phone: Doctor/HCP: Preferred hospital: DIAGNOSIS: Asthma Medication: Location: Triggers: Home medication:

IF YOU SEE THIS DO THIS • Wheezing Contact health room • Coughing Do not send student to health room alone • Shortness of breath/dyspnea Give medication as prescribed • Complaining of chest tightness Keep student sitting up and reassure student Encourage student to drink warm fluids

 If student's symptoms do not Call 911 improve in 5-10 minutes Notify parent  If cough becomes productive Call school nurse:  exhalation longer than inhalation Pager number:  Retractions seen in area below rib cage or in neck  Student becomes pale and sweaty.

 If student is in severe Call 911. distress Notify parent, principal and school nurse.  Unable to speak in full sentence  Bluish color  Severe restlessness  Decrease level of consciousness

Nurse signature:______Date:______

Physician signature:______Date:______INDIVIDUAL HEALTH/EMERGENCY CARE PLAN CONTACT INFORMATION

STUDENT:

E-MAIL: ______

NAME/Relationship #1 PHONE (Type) #2 PHONE (Type) #3 PHONE (Type)

Updated:

Parent signature:______Date:______