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|[pic] |School Health Services |
| |Donna Johnson, Director |
|Please return to: School_Booth Fickett | |
|Fax _731-3825 | |
| |Parent Form: Asthma Action Plan |
| |Student Asthma Action Plan |
| |Academic year: | |
| | | |
| | School: |Booth Fickett K8 |
| | | |
| |Name of School Nurse: |Kathy Stinely, RN |
| | | | | |
| |School Nurse Phone: | |Fax: |(520) 731-3825 |
|Name of Student | |Age | |Date of Birth | |
| | | | | | |
|Teacher | |Grade | |Room Number | |
| | | | |
|Asthma Care Physician | |Phone Number | | |
| | | | |
|Other Physician | |Phone Number | | |
| | | | |
|When my child is nearing an asthma episode, I notice the following signs (please circle all that apply): |
|Runny/Stuffy Nose Funny |Funny Feeling in Chest |Itchy Throat Sneezing|Itchy Chest |Tummy Ache |
|Feeling in Chest Itchy | |Coughing Watery Eyes | | |
|Throat Itchy Chest Tummy | |Circle Under Eyes | | |
|Ache | | | | |
|Feeling Weak |Headache |Dry Mouth |Getting Upset |Nervous |
|Sad |Sneezing |Coughing |Watery Eyes |Circle Under Eyes |
|Other (please list): | | |
| | | |
|My child's asthma triggers (things that start an asthma attack) are (please circle all that apply): |
|Animals With Fur Dust Cigarette Smoke Strong Smells |
|Cold Air Humid Air Colds Sinus Infections |
|Exercise (Running, Sports) Aerosols (Hair Spray, Perfume) Emotions (Sad, Happy) |
|Cockroaches Mold |
| |
|Food (please list): | |
| |
|Other (please list): | |
| |
I have reviewed my child’s action plan with the school nurse and believe all of the information to be accurate. I agree to notify the school nurse of any changes in my child’s condition including emergency room visits and hospitalizations. I give the school nurse and my child’s physician permission to contact one another or my insurance/Medicaid carrier for the purpose of obtaining information related to my child’s health. A reasonable effort will be made to obtain the information from me prior to any other source.
Parent/Guardian Signature __________________________________ Date _______________
Please have your physician complete the Physician Asthma Action Plan
Return both forms to School Nurse
|[pic] |School Health Services |
| |Donna Johnson, Director |
| |Physician Form: Asthma Action Plan |
| | |
|Please return to: |School |
| |Booth Fickett K8 |
| | |
| |Address, |
| |450 S Montego Dr |
| | |
| |City/State/Zip |
| |Tucson, AZ 85710 |
| | |
| |Nurse: |
| |Kathy Stinely, RN |
| | |
| |Fax |
| |(520) 731-3825 |
| |Phone |
| |(520) 731-3817 |
| | |
|Student Name | |Physician: | |
|DOB: | | | |
|POSSIBLE WARNING SIGNS |PEAK FLOW |TREATMENT PLAN |
| |ZONES | |
|sleeping without symptoms | |Long-term Control - Daily Medications |
|able to do normal activities without symptoms |GREEN |Medicine How Much Frequency |
|OR |ALL | |
|peak flow 80 to 100% of predicted or personal |CLEAR! | |
|best | |Before exercise: |
| | |Take ( 2 or ( 4 puffs of |
|Student’s personal best peak flow meter |_________ to _________ | |
|reading is: _____________ | |minutes before exercise. |
|OR |Greater than | |
|Student's predicted peak flow meter reading |80% of Best of Predicted Peak Flow | |
|is: __________________ | | |
| | | |
|ALL CLEAR! | | |
|Early warning signs of asthma may be seen: | |QUICK RELIEF - For Mild/Moderate Symptoms |
|cold symptoms and/or fever |YELLOW | |
|coughing/wheezing but able to do normal |CAUTION! |First Medicine: |
|activities | |( 2 or ( 4 puffs or |
|shortness of breath with activity | |( by nebulizer one time |
|chest tightness |_________ to _________ | |
|waking at night with cough/wheeze | |Then: |
|OR |50- 80% of Best of Predicted Peak Flow|If improvement in 15 minutes: |
|peak flow 50 to 80% of personal best |This is NOT where the student should | |
| |be every day. |If no improvement in 15 minutes: |
| | | |
|BE CAREFUL! |TAKE ACTION | |
|This is an emergency, you need help! | |ALERT - For Severe Symptoms |
| |RED | |
|difficulty walking or talking |DANGER! |First, take this medicine: _________________________________ |
|uses neck/stomach muscles when breathing | |( 2 or ( 4 puffs or |
|needs rescue medication more frequently than | |( by nebulizer one time |
|every 4 hours | | |
|constant coughing |Below____________ |If feeling better or repeat peak flow is in yellow zone, call|
|worsening symptoms after treatments | |doctor and ask for further instructions |
|blue or gray lips or fingernails |Less than | |
|OR |50% of Best of Predicted |If no improvement or repeat peak flow is in red zone or nails|
|peak flow ................
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