Microsoft word - asthma action plan- ware county

Ware County School System
Ware County Board of Education, 1301 Bailey Street, Waycross, GA 31501 School Health Services
Phone: 912-287-2306 Fax: 912-287-2207 Email: lrivers@ware.k12.ga.us
Student Name:_______________________________________
DOB ___________
Date form completed ______________

School______________________________________________
Teacher:_____________________________________________
Parent /Guardian Name:_______________________________________ Physician:______________________________________________
I hereby request and authorize the principal and his/her designee to 1)administer or assist my child with the medication(s) or procedure(s) as
prescribed by his/her physician and as directed on the label of the current original container I provided. 2) I also give permission for my child’s
physician(s) to release any medical records to my child’s school health representative, 3) for the school to release medically related records to my
child’s physician(s), and 4) for the school to seek emergency medical services for my child if necessary.

PARENT/GUARDIAN SIGNATURE_____________________________________________
For exercise: Allbuterol MDI (Ventolin or Proventil) 2 4 puffs with spacer 15-30 minutes before exercise
¾ Immediate action is required when the above named student exhibits any of the following signs of an asthma Repetitive Cough Shortness of Breath Chest tightness Wheezing Retractions Steps to take during an asthma flair:
Give emergency asthma medications as listed below: Quick Relief Medications
Frequency
Reassess in 10 – 15 minutes and reclassify the child according to the following parameters: Cough Respiratory
Accessory muscle use or
Work of breathing or
retractions
shortness of breath
Normal Rate
Symptoms
continue
Normal --- the child may return to the classroom Continues with asthma symptoms -- continue with the medication in number 1 above every 15-30 minutes until EMS arrives Activate EMS (call 911) IF the student has ANY of the following symptoms: The student is too short of breath to walk, talk, or eat normally The student gets no relief within 10-15 minutes of quick relief medicines OR the child has any of the following signs: Persistent chest and neck pulling in with breathing Childs asthma symptoms continue as outlined in the table above I certify that this child has a medical history of asthma and has been trained in the use of the listed medication, and is judged by me to be: self-administering the listed medication(s), ________NOT capable of carrying and self-administering the listed medication(s). The child should notify the school staff if one dose of the asthma medication fails to relieve asthma symptoms for at least 3 hours. ___________________________________________ ____________________________________________________ ________________

Source: http://www.ware.k12.ga.us/departments/health/ASTHMA-ACTION-PLAN-%20Ware%20County.pdf