Minneapolis Public Schools s1

Asthma Emergency Care Plan F18

Student Name: ______Date: ______Birthdate: ______SS#: ______Grade/Room: ______Parent’s Name: ______Phone: (____)______Emergency Contact: ______Phone: (____)______Emergency Contact: ______Phone: (____)______Health Care Provider: ______Phone: (____)______Hospital In Case Of Emergency: ______Asthma History:______

Symptoms (If you see this) Actions To Take (Do this)

 Breathing trouble  Remain calm. Reassure and stay with student.  Unusually fast or slow breathing  Give medication  Breaths unusually deep or shallow Name: ______Route: Inhaler/Neb  Gasping for breath, wheezing or coughing Dose: ______Frequency: ______ Person feels short of breath Location of med: ______ Difficulty talking or walking  Notify school health office.  Tightness in chest, upset stomach, restless, anxious  Have student sit up and breathe evenly, breathing through nose,  Blue or gray discoloration or lips for fingernails and breathing out with pursed lips.  Other ______ Give room temperature water to sip.  Elevate arms to shoulder level and provide support for arms (desk or back of chair).  Notify parent/guardian/emergency contact.  Other ______

Call 911

 If no improvement 5-10 minutes after using medication OR if no medication available.  If worsening breathing symptoms  Chest and neck pulled in with breathing  Child is struggling to breathe  Trouble walking or talking  Lips or fingernails are gray or blue  Increasing anxiety, confusion

Signatures: Parent/Guardian ______School Nurse ______Date to be reviewed: ______cc: Parent, Teachers, Phy Ed Teacher, Transportation, Other ______

Prevention Strategies: (Check if applicable) Copy given to / date Copy given to / date ___ Teacher information given (date) ______Cover nose and mouth in cold weather ______Use inhaler before exercise ______

Provided courtesy of the Healthy Learners Asthma Initiative / Minneapolis Public Schools, Health Related Services www.healthylearners.org or 612-668-0850 ___ Avoid contact with animals in classroom ______Avoid known allergens (list) ______Student to take controller medications daily ______Other ______

Provided courtesy of the Healthy Learners Asthma Initiative / Minneapolis Public Schools, Health Related Services www.healthylearners.org or 612-668-0850