<p> ASTHMA</p><p>FORM 3 Individual Health Care Plan – To be used if no Consultant care plan available (Parents/Carer to complete for School)</p><p>Name: ………………………………………………………………………..</p><p>Date Of Birth:………………………………………………………………</p><p>Known Triggers:…………………………………………………………..</p><p>………………………………………………………………… ………………..</p><p>………………………………………………………………… ………………..</p><p>………………………………………………………………… ………………..</p><p>Review Date: ………………………………………………………………</p><p>Name of School: Stroud High School</p><p>Class/Form: …………………………………………………………… Date…………………………………………………………….</p><p>Name of School Nurse / Health Visiting Team:</p><p>……………………………………………………………………... Contact Tel No: …………………………………………………..</p><p>Contact Information</p><p>Family Contact 1 Family Contact 2</p><p>Name: ………………………………………………………………. Name: ……………………………………………………………….</p><p>Phone No. (Work): …………………………………………….. Phone No. (Work): ……………………………………………..</p><p>Phone No. (Home):…………………………………………….. Phone No. (Home):…………………………………………….. Relationship: ……………………………………………………… Relationship: ………………………………………………………</p><p>Clinic/Hospital contact G.P.</p><p>Name: ………………………………………………………………. Name: ……………………………………………………………….</p><p>Phone No: ………………………………………………………… Phone No. : ……………………………………………………….</p><p>Outline of procedure/condition requiring management:</p><p>Describe condition and give details of pupil’s individual symptoms:</p><p>------</p><p>------</p><p>------</p><p>Describe treatment required:</p><p>------</p><p>------</p><p>------</p><p>------</p><p>LOCATION OF EMERGENCY TREATMENT:</p><p>Signature(s):……………………………………………………………………….. Date:………………………..</p><p>Relationship to pupil: …………………………………………………………….</p><p>Head: …………………………………………………………………………………… Date:…………………………</p><p>Copy to: Parents School GP School Health Visiting Team EMERGENCY ACTION PLAN FOR SYMPTOMS OF ASTHMA</p><p>Actions:  Do not leave a child – send another staff member/student to get their spare inhaler and spacer.  Help the child to sit up and slightly forward – do not hug them or lie them down. Ensure tight clothing is loosened. Reassure the child. Important: REGARD EACH EPISODE AS BEING SEVERE BEFORE TREATING OTHERWISE. FAILURE TO RESPOND TO TREATMENT AT ANY STAGE REQUIRES IMMEDIATE 999 AMBULANCE ASSISTANCE Moderate Asthma Severe Asthma Life Threatening Asthma Signs and Symptoms Signs and Symptoms Signs and Symptoms</p><p> Able to talk  Struggles to talk, drink or eat  Unable to talk, drink or eat  Breathless  Takes several breaths to  Poor or no effort of  Increase in respiratory rate  complete a sentence breathing  Excessive use of breathing  Exhaustion, altered,  Muscles consciousness , agitation,  Wheeze may or may not be confusion present  Wheeze may or may not be present  Silence is common at this point if exhausted Treatment Treatment Treatment 1. Give 10 puffs of Salbutamol 1. Give 10 puffs of 1. Basic Life Support if metered dose inhaler (blue) Salbutamol metered dose required. (100mcg/puff) via an inhaler inhaler (blue) (100mcg/puff) (and spacer device where via an inhaler (and spacer 2. Dial 999 for ambulance. available). device where available). 3. Give 10 puffs of 2. If improved with initial 10 2. If improved with initial 10 Salbutamol metered dose puffs child safe to go home puffs child safe to go home inhaler (blue) (100mcg/puff) with parent but should be with parent but should be via an inhaler (and spacer encouraged to seek GP review. encouraged to seek GP review. device where available).</p><p>3. If no improvement repeat 3. If no improvement repeat 10 puffs of Salbutamol 10 puffs of Salbutamol 4. Repeat above every 10-15 metered dose inhaler (and metered dose inhaler (and minutes until ambulance spacer device where available) spacer device where available) arrives. after 10-15 minutes and after 10-15 minutes and ensure 999 called for an ensure 999 called for an 5. A member of staff should ambulance. ambulance. always accompany a child taken to hospital by ambulance and stay with them until their parent arrives. Agreement for the administration of Asthma Reliever</p><p>Name of Student: …………………………………………………………………..</p><p>School: Stroud High School</p><p>Date of Birth: ………………………………………… Year/Group: …………………………………………………</p><p>Address: ……………………………………………………………………………………………………………………….</p><p>…………………………………………………………………………………………………………… ………………………</p><p>…………………………………………………………………………………………………………… ………………………</p><p>Telephone Number: (H) ………………………………………….. (W)……………………………………………</p><p>(M)………………………………………….. </p><p>G.P. Name: ……………………………………………………………. Tel No: ………………………………………</p><p>Known Allergies: ……………………………………………………………………………………………………………………………………..</p><p>…………………………………………………………………………………………………………… ………………………..</p><p> The Reliever inhaler shall be kept in a safe, accessible place agreed between staff and parents.  A spare Reliever inhaler and spacer (where prescribed) is provided by parents and storage noted.  Volunteer staff shall be trained in the management of Asthma – one person to be available at all times.  Parents/carers are responsible for maintaining the inhalers/washing the spacer and ensuring reliever treatments in date.</p><p>Name: (Print) …………………………………………..</p><p>Signed: ……………………………………………………. Date:………………………………….</p><p>Name: (Print) …………………………………………..</p><p>Signed: ……………………………………………………. Date:………………………………….</p><p>I give my approval for volunteer employees to administer Asthma relievers and act as laid out in the actionplan in the event of an emergency.</p><p>Head Teacher Name: (Print) …………………………………………………. Signed: ……………………………………………………. Date:………………………………….</p>