Student Asthma Action Card

Northeast Indiana Pediatric Specialists, PC

 

Name__________________ Grade _______ Age______

Teacher___________________________ Room_________

Parent/Guardian__________________________________

Phone: Home__________________Work________________

Emergency Contact_______________________________

Relationship____________________ Phone_____________

Physician: _______________________ Phone:________________

 

Daily Asthma Management Plan

 

Identify the things, which trigger an asthma episode

 

 

 

 

 

Control of School Environment

(List any environmental control measures; pre-medications, and/or dietary restrictions that the student needs to prevent an Asthma attack)

 

 

 

 

 

 

 

Peak Flow Monitoring

 

Personal best Peak flow number  ________    ________    ________

Monitoring times: ________    _________   _________   ________

 

Daily Medication Plan

      Medication                          Dose                                   When              

 

1. ______________________        ___________________

 

2>_______________________         ____________________

 

3>_______________________         ____________________

 

4>_______________________         ____________________

 

5>_______________________         ____________________

 

 

 

 

School Emergency Plan

 

Emergency action is necessary if the student has symptoms such as_______________________________________________

 or a Peak flow reading of ________________________

 

Ø       Steps to take during an asthma attack

o        Give medications as listed below

o        Contact parent if__________________________________________

o        Seek emergency medical care if the student has any of the following

§         No improvement 15 – 20 minutes after initial tx with med and a relative cant be reached

§         Peak Flow of _______________

§         Hard time breathing with

·         Chest and Neck pulled in with breathing

·         Child is hunched over

·         Child is struggling to breathe

§         Trouble walking or talking

§         Stops playing and cant start activity again

§         Lips or fingernails are grey or blue

 

Ø       Emergency Asthma Medications

 

1.         

 

2.        

 

3.        

 

Ø      Comments/Special Instructions

 

 

 

 

 

 

For inhaled medications

____ I have instructed ___________________ in the proper way to use his/her medications.  It is my professional opinion that ____________________ should be allowed to carry and use that medication by him/herself.

 

____ It is my professional opinion that _________________ should not carry his/her inhaled medication by him/herself

 

 

Physician Signature                                               

Date ______________________                                                  

 

Parent Signature                       ___________________ Date_______________________