Albuquerque public schools

School Name: __________________________ ASTHMA ACTION PLAN
Student Name________________________________ Date of Birth ____________School___________________________ Student ID Number________________________ Grade ____Medication Allergies__________________________________ Activities student participates in at school: _________________________________________________________________
Asthma symptoms are triggered by:
Exercise Illness Pollen Smoke Dust Air Pollution Animals Cold Air Molds Foods (list) Please list any other triggers: ___________________________________________________________________________ Usual Asthma Symptoms: Cough Shortness of Breath Chest Tightness Wheeze Other___________ If a student has any of the following symptoms: chest tightness, difficulty
Call 911 for any of these!
breathing, wheezing, excessive coughing, shortness of breath
1. Stop activity & help student to a sitting position
If breathing does not improve after medication is given
2. Stay calm, reassure student
Student is having trouble walking or talking
3. Assist student with the use of their inhaler
Student is struggling to breathe
4. Escort student to the health room or call for health room staff for
Student’s chest and/or neck is pulling in while breathing
immediate assistance. Never send the student to the health room alone!
Student’s lips are blue, and/or
INHALER IS KEPT: __________________________
Student must hunch over to breathe
HEALTH CARE PROVIDER, Please complete all items in box: ICD 9 Code: 493.9 or ________
Asthma Severity: Intermittent Mild persistent Moderate persistent Severe persistent
Controller Medication given at home:
__________________________________________________________________________________________________
Name
__________________________________________________________________________________________________ Name
Quick Relief Medication:
Albuterol ____puffs every ___ min. and as needed up to ___ puffs per hour. May repeat every___hrs Albuterol 10-15 min before exercise Routinely As Needed. Activity limitations: ________________
OR, Albuterol or (___________________) solution as needed, _____ mg by nebulizer every ____ to ____hours
Asthma Symptoms
Asthma Symptoms
Asthma Symptoms
Take Quick Relief Medication Now!
Take Quick Relief Medication Now!
Use quick relief inhaler before exercise
Call 911 & continue to give Quick
Relief Medication every 20 minutes
until EMS arrives!
Parent/guardian-call medical provider if
Student can self carry medication? Yes □ No □.
Student can self-administer medication? Yes □ No □
Provider signature_____________________________Date ___________Provider printed name______________________________
Provider phone___________________________Provider fax________________________Provider email______________________
Parent/Guardian signature_______________________________________________Date______________________________________ Home phone__________________________ Cell phone ______________________Work phone ________________________________ School Nurse signature ________________________________Date_____________Phone_____________________________________ Assess the effectiveness of the IHP and AAP

Source: http://www.corralesinternationalschool.org/pdf/AsthmaActionPlan.pdf