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Asthma Action Plan

Required

Studentrequired
First Name
Last Name
Must contain a date in MM/DD/YYYY format
Inhaler: Select one:required1-2 puffs - 15 minutes prior to gym or sports or Q4 hours PRN.
1-2 puffs - 15 minutes prior to gym or sports or Q4 hours PRN.
Medication to be kept in Nurse’s Office and administered by School RN.
Please be advised that all medication for Elementary students will be kept in Nurse’s Office.
Student may self carry inhaler and administer medication as per MD orders
High School & Middle School ONLY. Elementary students may not self carry inhalers.
Immediate action is required if student exhibits any of the following signs of respiratory distress:
Repetitive Cough - Shortness of Breath - Chest Tightness - Wheezing - Retractions
Steps to take during asthma exacerbation:
1. Administer emergency asthma medication as prescribed below with inhaler or nebulizer:
2. Reassess 10-15minutes after medication administration.
→ If S & S have resolved, student may return to classroom.
→ Activate 911, if S & S above persist or if student continues to struggle to breathe.
→ Repeat emergency medication after 30 minutes if EMS has not arrived
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Must contain a date in MM/DD/YYYY format
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Then call:
Parent/Guardianrequired
First Name
Last Name

DO NOT HESITATE TO CALL 911!

Attach up to 1 file with a maximum size of 10MB
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Must contain a date in MM/DD/YYYY format

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