STUDENT ASTHMA/ANAPHYLAXIS ACTION PLAN

STUDENT ASTHMA/ANAPHYLAXIS ACTION PLAN

A physician must fill out the appropriate treatment plan for your child and sign the form. Please do not submit this form until his physician has completed it. If you wish to use the electronic version, you may download a PDF copy to print.
STUDENT NAME*
Date of Birth*

MonthDayYear
Date
Exercise Precaution: Administer inhaler (2 inhalations) 15-30 min before exercise.

Albuterol inhaler (Proventil, Ventolin)Levalbuterol (Xopenex HFA)Pirbuterol inhaler( Maxair)Use inhaler with spacer device:May carry and self-administer metered-dose inhalerOther
ASTHMA TREATMENT: Give quick relief medication when student experiences asthma symptoms, such as coughing, wheezing or tight chest.

Albuterol inhaler (Proventil, Ventolin) 2 inhalationsUse inhaler with spacer devicePirbuterol inhaler (Maxair) 2 inhalationsLevalbuterol (Xopenex HFA) 2 inhalations1.25 mg/ 3 ml Albuterol inhaled by nebulizer (Proventil, Ventolin, AccuNeb)2.5 mg/ 3 ml Albuterol inhaled by nebulizer (Proventil, Ventolin, AccuNeb)0.31 mg/3 ml Levalbuterol inhaled by nebulizer (Xopenex)0.63 mg/3 ml Levalbuterol inhaled by nebulizer (Xopenex)1.25mg/3 ml Levalbuterol inhaled by nebulizer (Xopenex)May carry and self-administer metered dose inhaler (Complete self-management form found on the medical page of Creighton Prep's website.)Other
CLOSELY OBSERVE THE STUDENT AFTER GIVING QUICK RELIEF ASTHMA MEDICATIONS

If after 10 minutes:
- If symptoms are improved, student may return to class after notifying parent
- If no improvements in symptoms, repeat the treatment.
- If student condition worsens, CALL 911 and initiate the Nebraska Schools' Emergency Response to Life-threatening Asthma or Systemic Allergic Reactions (Anaphylaxis)
ANAPHYLAXIS TREATMENT: Give Epinephrine when student experiences allergy symptoms such as hives, difficulty breathing, lips or fingernails turning blue or trouble talking.

Epinephrine injection (please specify):Epinephrine injection: EpiPen 0.3 mg 2-PakEpinephrine injection: EpiPen Jr. 0.15 mg 2-PakEpinephrine injection: Twinject 0.3 mgEpinephrine injection: Twinject 0.15 mgMay carry and administer Epinephrine injection (Complete self-management form found on the medical page of Creighton Prep's website.)Other
CALL 911 AND CLOSELY OBSERVE THE STUDENT AFTER GIVING EPINEPHRINE
- Notify parent/guardian immediately.
- Even if the student improves, the student should be observed for recurrent symtoms of anaphylaxis in an emergency medical facility.
- If student condition worsens, initiate the Nebraska Schools' Emergency Response to Life-threatening Asthma or Systemic Allergic Reactions.
This student has a medical history of asthma and/or anaphylaxis and I have reviewed the use of the above-listed medication(s). If medications are self-administered, the school staff MUST be notified.
Additional information
Physician name *
Physician phone*
Physician signature*

Clear
Date*

MonthDayYear
Date
Parent name *
Parent Phone*
Please enter a valid phone number.
Parent signature*

Clear
Date*

MonthDayYear
Date
For additional copies and references, go to http://www.attackonasthma.org
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