STUDENT ASTHMAIANAPHYLAXIS ACTION PLAN

STUDENT ASTHMA/ANAPHYLAXIS ACTION PLAN

A physician will need fill out the appropriate treatment plan for you son 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 excersie

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 inhalations.Use inhaler with spacer devicePirbuterol inhaler (Maxair) 2 inhalationsLevalbuterol (Xopenex HFA) 2 inhalations.1.25 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 inhalerOther
CLOSELY OBSERVE THE STUDENT AFTER GIVING QUICK RELIEF ASTHMA MEDICATIONS

If after 10 minutes:
- Symptoms are improved, student may return to class after notifying parent
- NO improvements in symptoms, repeat the treatment
- If student condition worse, CALL 911 and initiate the Nebraska School's Emergency response to Life-threating Asthma or Systemic Allergic Reactions
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):EpiPen 0.3 mg 2-PakEpiPen Jr. 0.15 mg 2-PakTwinject 0.3 mgTwinject 0.15 mgMay Carry and Administer Epinephrine injectionOther
CALL 911 AND CLOSELY OBSERVE THE STUDENT AFTER GIVING EPINEPHRINE
- Notify Parents Immediately
- Even if the student improves, the student should be observed for recurrent symtoms of anaphylaxis in an emergent medical facility
- If student condition worse, INITIATE the Nebraska Schools' Emergency response to Life-threating Asthma or Systemic Allergic Reactions
Additional information
Physician name *
Phone*
Physician signature*

Clear
Date*

MonthDayYear
Date
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.
Parent name *
Parent signature*

Clear
Date*

MonthDayYear
Date
For additional copies and references, go to http://www.attackonasthma.org
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STUDENT ASTHMA/ANAPHYLAXIS ACTION PLAN