Emergency Department Pediatric Asthma Care Map MEDICATION ADMINISTRATION RECORD (MAR) METERED-DOSE INHALER/SPACER Wt ______Refer to: Diabetic Flowsheet ICU Flowsheet KEY Epidural Flowsheet D/C = discontinued PCA Flowsheet ALLERGIES:

MEDICATION ORDERED YEAR 20 _____ MEDICATION GIVEN

DATE MEDICATION INITIALS DATE INITIALS DD/MONTH (IF DIFFERENT) GIVEN TRAN- NURSE BY ND SCRIBER 2 IF TIME NAME DOSE ROUTE INSTRUCTIONS TIME NEEDED Salbutamol (100 mcg/puff) 8 puffs and Ipratropium Bromide (20 mcg/puff) 3 puffs via metered-dose inhaler

Dexamethasone ______mg po x 1 dose (dose = 0.6 mg/kg/dose – rounded to the nearest 2 mg, maximun 10 mg/dose) OR Prednisone/Prednisolone ______mg po x 1 dose (dose = 1 mg/kg/dose rounded up to the nearest 5 mg, maximum 50 mg/dose) OR Methylprednisolone ______mg IV x 1 dose (dose = 2 mg/kg/dose, maximum 125 mg/dose)

Salbutamol (100 mcg/puff) 8 puffs and Ipratropium Bromide (20 mcg/puff) 3 puffs via metered-dose inhaler

Salbutamol (100 mcg/puff) 8 puffs and Ipratropium Bromide (20 mcg/puff) 3 puffs via metered-dose inhaler

Salbutamol (100 mcg/puff) 8 puffs via metered-dose inhaler

FORM #W-00070L 07/11 Emergency Department Pediatric Asthma Care Map Page 1 of 2 Developed by the Child Health Program – Winnipeg Regional Health Authority Emergency Department Pediatric Asthma Care Map MEDICATION ADMINISTRATION RECORD (MAR) METERED-DOSE INHALER/SPACER Wt ______Refer to: Diabetic Flowsheet ICU Flowsheet KEY Epidural Flowsheet D/C = discontinued PCA Flowsheet ALLERGIES:

MEDICATION ORDERED YEAR 20 _____ MEDICATION GIVEN

DATE MEDICATION INITIALS DATE INITIALS DD/MONTH (IF DIFFERENT) GIVEN TRAN- NURSE BY ND SCRIBER 2 IF TIME NAME DOSE ROUTE INSTRUCTIONS TIME NEEDED

07/11 Emergency Department Pediatric Asthma Care Map Page 2 of 2 Developed by the Child Health Program – Winnipeg Regional Health Authority