High School Middle School Elementary School

CLOVERLEAF LOCAL SCHOOLS

Office: 330-302-0328 Office: 330-302-0207 Office: 330-302-0103

Fax: 330-302-0530 Fax: 330-302-0520 Fax: 330-302-0080

Asthma: Emergency Action Plan

Student’s Name: / School/Grade:
Date of Birth: / Contact Teacher:
Parent/Guardian Name: / Phone (Family):
Address
Physician: / RN:
Emergency Number:
Emergency Number:
Emergency Number:

Known asthma triggers:

____ Cat/Dog _____Pollen ______Mold ______Dust/dust mites ______Cold Air ____ Smoke

____ Fragrance/Perfumes _____ Humidity _____ Foods (list): ______

____Exercise ___Other (list): ______

If you would prefer your child to self-carry their asthma inhaler, both signatures are required below:

______This student received instruction/returned demonstration in the use of their asthma

(prescriber’s signature) inhaler by a trained staff member. The student has been instructed on proper time

intervals and specific symptoms indicating need for self administration. It is my

recommendation that this student carry their asthma inhaler on them at all times.

The student is to notify school personnel when medication is not effective (15 minutes

after administration). Medication is not to be shared with others.

______As the parent/guardian of this student, I authorize my child to possess and use an

(parent/guardian signature) asthma inhaler as prescribed, at the school and any activity, event or

program sponsored by or in which the student’s school is a participant. My child

demonstrates proper administration and has shown responsible behavior when it comes

to carrying this medication. My child will notify school personnel when medication is not

effective (15minutes after administration or immediately for severe symptoms).

Student’s Name & Grade: ______

Date of Administration to Start & End: ______

1, Asthma Inhaler (brand and strength): ______

Dose/ how many puffs/time: ______

With Spacer ______No spacer required ______

Adverse reactions/special instructions:______

2. Other medication (brand, strength and dose):______

Route & Time: ______

Adverse reactions/special instructions:______

I agree that the trained school staff may follow the asthma pathway as stated:

1st dose: 2 puffs of albuterol inhaler or 1 ampule nebulized as directed. Observe for 20 minutes & return to class if

symptoms have improved. Record heart rate and oxygen if pulse-ox device available.

2nd dose: If symptoms are still present after 20 minutes, repeat quick relief medication as ordered and observe for

20 minutes. Return to class if symptoms have improved. Record heart rate and oxygen if pulse-ox

device available.

3rd dose: If symptoms are still present after waiting 20 minutes after 2nd dose, repeat quick relief medication as

ordered and call parent and physician’s office. Student is to remain in the presence of trained school staff

until parent arrives. Record heart rate and oxygen if pulse-ox device available.

This plan is subject to change but only with documentation from physician along with meeting with parents and staff. This plan will be shared with all teachers, support staff and transportation that are involved with student’s school day.

I am in agreement with this plan of care and understand it will be shared as needed with members of the school staff to safeguard and promote the health of the student listed above while at school. I will notify the school immediately if the health status of the

student listed above changes, we change physicians, or there is a change or cancellation of the physicians orders.

Parent/Legal Guardian ______Date______

RN: ______Date______

MEDICAL REVIEW

I have reviewed the attached Individual Emergency Action Plan (EAP) for ______AND

______I approve the EAP as written

______I approve the EAP with the attached amendments

______I do not approve of the EAP as written and a substitute orders are

attached.

Physician ______Date______

Other Recommendations:

2015/asthmaEAP/dmd