Iredell-Statesville Schools s2

SCHOOL ASTHMA RECORD And Emergency Action Plan

Please Complete both sides of the emergency medical plan for Asthma and add any further instructions you wish for your child. Return to School Nurse as soon as possible.

NAME OF STUDENT ______

1. Briefly describe what causes the child’s asthma symptoms (weather, cold, allergies, and exercise):

2. How often does the child have a bad enough asthma attack that he/she needs to see a doctor or go to the hospital?

3. Name any medication that the child takes for his/her asthma (how often and how much):

At home ______

At school ______

4. Does your child suffer any side effects from these medications? If so, please list them here:

5. Name any activities/exercise in which your child CAN NOT participate.

6. What does your child do at home to relieve wheezing during an asthma attack? (Please check any that apply).

______Breathing exercises Takes medicine: ______Inhaler

______Rest/relaxation ______Nebulizer

______Drinks liquids ______Oral medicine

7. Do you know your child’s baseline peak flow rate? ____ Yes ____ No If so, what is it? ______

8. If medications/inhaler/nebulizer are to be kept or taken at school, a medication authorization form must be completed by parent and physician and kept at school. These are obtained from your school nurse. This form is completed every year.

OVER 3/2011 STUDENT NAME______TEACHER______GRADE______BUS#______PRIMETIME ____am ____pm CAR RIDER ____ am _____ pm

PARENT/GUARDIAN______HOME PHONE ______WORK PHONE______CELL PHONE ______PRIMARY PHYSICIAN______PHONE ______ASTHMA SPECIALIST ______PHONE ______HOSPITAL______Asthma is a reversible obstructive lung disease with hyperactive airways caused by a variety of stimuli. It is characterized by constriction of the bronchial smooth muscle, edema and inflammation of the mucous membranes lining the airways, and increased secretion of sticky mucous. The results are decreased air flow on inspiration and difficulty in expiring air from the lungs.

Please circle the signs and triggers pertinent to your child and add additional ones if needed. SIGNS OF ASTHMA ATTACK TRIGGERS OF ASTHMA 1. coughing (often the earliest sign) 1. environmental pollutants 2. wheezing 2. exercise 3. rapid pulse (120 or greater) 3. cold air 4. labored breathing 4. emotions 5. increased use of accessory muscles 5. infections 6. ______6. ______NOTE: The child who is having an asthma attack with NOTE: It is rare to have only one triggering factor. significant respiratory distress is in more danger when wheezing cannot be heard and breath sounds are minimal.

Please add information as necessary that is pertinent to your child. A. PREVENTION 1. Avoid known triggers if possible 2. Promote exercise when child is asymptomatic. List activity restrictions: ______3. Give plenty of water, clear liquids, etc. 4. Add other instructions as needed: ______B. DURING AN ATTACK 1. Keep calm. Reassure the child by your tone of voice and your attitude that you are able to manage the situation. 2. Administer prescription medication for acute attack (if provided by parent/available). List emergency medication your child uses for an attack: ______3. Allow child to assume a position most comfortable for him/her and encourage relaxation. 4. Have student sip tap water slowly for hydration (not cold). 5. Instruct child to breathe in deeply, hold his/her breath 1 or 2 seconds, then cough twice—first to loosen mucous, and second to bring it up. Swallowed mucous may cause nausea and vomiting. 6. Add other instructions as needed: ______C. IF CONDITION DOES NOT IMPROVE 1. Notify parent and recommend immediate medical care. 2. In severe cases, summon emergency medical services. 3. Add other instructions as needed: ______

I authorize the release and exchange of medical and educational information between my child’s physician and school staff necessary in carrying out this service to my child.

PARENT/GUARDIAN SIGNATURE______DATE______

SCHOOL NURSE SIGNATURE______DATE______