Asthma Management and Emergency Care Plan Child’s Name

Date of Birth:

Health Card Number:

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MedicAlert® Number: Click here to enter text.

Does your child carry an Emergency Health Services (EHS) Special Patient Protocol card with them? Yes ☐ No ☐ Allergies: Click here to enter text.

Medical Diagnosis(es): Click here to enter text.

Is your child aware of their diagnosis? Yes ☐ No ☐

Identification

Does your child experience fears and/or anxiety related to their health care needs/medical diagnosis? Yes ☐ No ☐ If yes, please describe helpful coaching/support/management strategies: Click here to enter text. Place Photo Here Medications required during school hours: N/A ☐

Location where medication is stored at the school (refer to Board policy)

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Bus Driver(s) and Bus numbers(s) (if applicable): Morning Bus: Click here to enter text.

Afternoon Bus: Click here to enter text.

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This plan has been shared with bus operators, and /or other school designated person(s) providing transportation Yes ☐ N/A ☐

Does your child have any activity restrictions while at school? Yes ☐ No ☐ If yes, please describe: Click here to enter text.

Identification

Emergency Contacts: Please prioritize 1,2,3, in the order the calls are to be placed: Name Relationship Home Phone Work Phone Cell Phone Number Number Number 1. 1. 1. 1. 1. 1. 2.

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E-Mail

Identify the preferred method of communication, for non-emergency situations ☐Phone call ☐Text ☐Email ☐Communication book/agenda ☐Other; please specify: Click here to enter text. Additional Information: Click here to enter text.

Designated school staff with asthma training: (to be completed by school staff) 1. Click here to enter text.

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Definition

Asthma is a chronic (long-term) disease affecting the airways (breathing passages) in the lungs. People with asthma have extra sensitive airways, and various things can trigger their airways to become red, swollen, constricted and/or filled with mucous, making it difficult to breathe.

Communication

Notify parent/guardian if (check all that apply): ☐ Symptoms persist 5-10 minutes after receiving one dose of reliever medicine (e.g. Ventolin ®/Salbutamol) ☐Each time the reliever medicine (e.g. Ventolin ®/Salbutamol) is administered in school ☐Other; please specify Click here to enter text.

Exercise Procedure

Triggers

Identify asthma triggers for your child as they apply to school: ☐Colds/viral infections ☐Exercise/physical activity ☐Weather/temperature changes/seasonal ☐ Scents ☐Anxiety/stress ☐Allergies; please specify Click here to enter text. ☐Other; please specify: Click here to enter text. Describe strategies to manage triggers at school: Click here to enter text.

If exercise/physical activity triggers your child’s asthma, list steps in order your child should follow prior to gym class, recess, or other physical activity. Please include if the reliever medication is required prior to the activity: Click here to enter text.

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Describe strategies that help your child stay calm in the event of an asthma flare-up:

Emotional Support

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Symptoms

Asthma Flare-up symptoms include (but are not limited to):  Frequent cough especially after or during exercise.  Wheezing (a high pitched musical sound when breathing), which may get worse with exertion.  Chest tightness.  Faster, harder breathing.  Persistent cough after coming from playing outside or with temperature change. Severe Asthma Flare-up/ “Asthma Attack” symptoms include (but are not limited to):  Indrawing (the skin is “sucked in” with each breath at the neck and/or around the collar bone  Shortness of breath at rest or when talking (can only say three to five words between breaths).  Tripod stance (leaning over hands on wall, knees or table)  Worsening of symptoms despite medication use.

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Typical symptoms for your child- check those that apply: ☐Cough ☐Wheeze ☐Shortness of breath ☐Chest tightness ☐Other, as it applies to your child; please specify: Click here to enter text.

Reliever Medication Information

Identify the prescribed reliever medication (medication used during a flare-up) ☐Ventolin ®/ Salbutamol ☐Bricanyl ® ☐Other; please specify: Click here to enter text. Identify the device to be used with the reliever medication, if applicable: ☐Spacer with a facemask ☐Spacer with a mouthpiece ☐Aerosol compressor ☐Diskus ☐Turbuhaler Note: Attach step by step instructions for use if staff are to administer the medication, or support your child while they self-administer.

Location of the reliever medication in the school: Click here to enter text. Note: Reliever medications are considered emergency medications and therefore must be stored in safe, unlocked, and accessible locations. (Refer to your School Board’s policy)

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Onset of Asthma Symptoms  

Have the student sit down and rest. DO NOT lay the student down. Speak calmly and do not panic. Keep student calm by using techniques specified by the parent/guardian in the plan.

Administer a dose of the prescribed Reliever Medication

Emergency Action Plan

 

Stay with the student. Remind the student to take slow breaths in through the nose and exhale out through their mouth.

Improvement of symptoms (within 5-10 mins)

No change (within 5-10 mins)

Symptoms worsen (within 5-10 mins)

nd

Able to resume activity as tolerated

Notify parent/guardian as directed

Administer 2 Dose of Reliever Medication

Improvement in symptoms (within 5-10 mins)

Do not resume activity!  

Stay with student Phone parent/guardian and follow their direction

No change or symptoms worsen

Phone 911  



Call or notify parent/ guardian Administer the prescribed reliever medication as needed until paramedics and/ or parent/guardian arrives. Stay with student until paramedics and/or parent/guardian arrives.

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Parent/Guardian/Student (if appropriate) Authorization Re: Consent to Release Information of the Health and/or Emergency Care Plan I authorize and hereby consent for school staff to use and/or share information found on this form for purposes related to the education, health, and safety of my child. This may include but is not limited to: 1. Display of my child's photograph in hard copy or electronic format so that staff, volunteers, and school visitors will be aware of his/her medical condition. 2. Place a copy of this plan in appropriate locations in the school including storing an electronic copy in my child’s confidential record. 3. Communication with school bus operators, or other school designated person(s) providing transportation. 4. Any other circumstances that may be necessary to protect the health and safety of my child. ___________________ Date

Consent & Authorizations

___________________ Date

___________________________________________________ Parent/Guardian Signature ___________________________________________________ Student (if appropriate)

Parent/Guardian/Student (if appropriate) Authorization Re: Consent for Implementation of the Health and/or Emergency Care Plan I have provided the information above and agree with the identified health care needs, interventions and/or the emergency responses outlined in this plan. I am aware that school staff are not medical professionals and will perform all aspects of the plan to the best of their ability and in good faith. ___________________ Date ___________________ Date

___________________________________________________ Parent/Guardian Signature ___________________________________________________ Student (if appropriate)

Note: It is the parent(s)’/guardian(s)’ responsibility to notify the principal if there is a need to change the Health and/or Emergency Care Plan throughout the school year. This authorization may be cancelled upon receipt of written notification to the principal.

Authorizations ___________________ Date

___________________________________________________ Regulated Health Care Professional Signature and Designation ___________________________________________________ Print Name

___________________ Date

___________________________________________________ Principal ___________________________________________________ Print Name Plan is effective on: (insert date) ____________________________________ NOTE: Plans need to be reviewed, updated, and signed annually.

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Asthma Management and Emergency Care Plan (revised June 2015 ...

Medical Diagnosis(es):. Click here to enter text. Place Photo Here. Is your child aware of their diagnosis? Yes ☐ No ☐. Does your child experience fears and/or anxiety. related to their health care needs/medical. diagnosis? Yes ☐ No ☐. If yes, please describe helpful. coaching/support/management strategies: Click here to ...

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