Asthma management plan



Child’s Name _______________________________________ Date of Birth _____________ School _____________________________ Grade _______
Parent/Caregiver _________________________________ Phone (H) ________________ Phone (W) ________________ Phone (Cell) _______________
Address ______________________________________________________________ City _______________________________ Zip ________________
Emergency Contact _________________________________________________ Relationship _______________________ Phone ___________________
Name of Physician _______________________________________________________________ Office phone number ___________________________
What triggers your child’s asthma attack: (Check all that apply)
… Illness
… Food ___________________________________________________ … Allergies … cat … dog … dust … mold … pollen … Other __________________________________________________ Describe the symptoms your child experiences before or during an asthma episode: (Check all that apply) … Cough
The child’s asthma is:
… mild persistent … moderate persistent … severe persistent … EXERCISE-INDUCED
Peak Flow
Symptoms OR Monitoring Treatment

Controllers How
> ____________
… Albuterol (with spacer/nebulizer) 2 puffs 1 minute apart q4° prn YELLOW ZONE
1. … Continue daily controller medications
2. Give albuterol 2-4 puffs (one minute between puffs) with spacer or 1 nebulizer treatment, wait 20 min.
… If no improvement, repeat 2-4 puffs. Wait 20 minutes. _____ to ______
… If no improvement, repeat 2-4 puffs. This will be 3 doses in one hour, proceed to 3 3. If child returns to Green Zone:
… Continue to give albuterol 2 puffs every 4 hours for 1 to 2 more days AND … Increase controller to _____________________________________________ for next 7 days 4. … No physical exercise … Physical exercise as tolerated
If child remains in Yellow Zone for more than 1-2 days or requires albuterol more than every 4
hours, call your doctor NOW!
Give albuterol (2 puffs with spacer) NOW, and repeat every 20 minutes for 2 more doses OR give 1
dose nebulized albuterol – Call your doctor
Seek emergency care or call 911 if:
Child is struggling to breathe and there is no improvement 20 minutes after taking albuterol < ____________
Chest or neck is pulling in with breathing … Student is able to perform procedure alone and may carry … Student is able to perform procedure with supervision the inhaler with them, consult school nurse for local protocol … Student requires a staff member to perform procedure ; More than 2 absences related to asthma per month ; Albuterol is being used as a rescue medication 2 times per week at school ; The child is persistently in the Yellow Zone _________________________________________________________ I give my permission for school personnel to follow this plan, administer medication and care to my child and contact my physician if necessary. I assume full responsibility for providing the school with prescribed medication and delivery/monitoring device. I approve this Asthma Management Plan for my child. _______________________________________



2013 BOARD OF COMMISSIONERS Ronald P. Feldman, Vice President (Ward 6) UPPER DUBLIN Montgomery County, PA 2013 SCHOOL BOARD Michael Pladus, Superintendent of Schools TREASURER & REAL ESTATE TAX COLLECTOR TOWNSHIP STAFF Jonathan K. Bleemer, Asst. Twp. Manager/Finance Director Richard Barton, Code Enforcement Director Derek Dureka, Parks & Recreation Director

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