ASTHMA Sample Emergency Care Plan for Unlicensed School Personnel: Name: DOB: Gender: M F Teacher/HR: Grade: Date: Emergency Contact Information Name Relationship Phone Parent/Guardian Home:___________________________ Other- List relationship Cell:_____________________________ ___________________ Work: Parent/Guardian Home:___________________________ Other- List relationship Cell:_____________________________ ___________________ Work: Asthma triggers for this student (Except for exercise, please minimize student exposure to triggers when able): Strong Odors Mold Smoke Temperature Changes Animal (Specify): Exercise Exhaust Fumes Respiratory Infections Other (Specify): Pest Urine/Droppings Laughing/Crying WATCH TAKE THESE ACTIONS for any of the following signs of an asthma episode when you see any of the signs listed Call for at:__________________ Difficulty walking or talking, whispers Stops playing or cannot participate in Never leave student unattended activities Assist student to take own quick relief Complains of neck feeling funny or medicine if available something stuck in their throat or frequent If nurse is not available or if student throat clearing does not improve after using own Coughing frequently medicine call 911 or call for – Appears anxious or restless emergency transportation in Sits or stands hunched over accordance with district policy Difficulty breathing, gasping, flared nostrils, Notify parent/guardian audible wheezing sounds with breaths Lips or fingernails are blue or grey This plan was developed by the School Nurse (RN) below and reviewed with staff members. School Nurse Name: Date: School Nurse Signature: Copy to Parent (Optional) School Nurse Phone Contact:
Sample Emergency Care Plan for Unlicensed School Personnel: ASTHMA Name: DOB: Gender: M F Teacher/HR: Grade: Date: Emergency Contact Information Name Relationship Phone Parent/Guardian Other- List relationship ___________________ Home:___________________________ Cell:_____________________________ Work: Parent/Guardian Other- List relationship ___________________ Home:___________________________ Cell:_____________________________ Work: Asthma triggers for this student (Except for exercise, please minimize student exposure to triggers when able): Strong Odors Mold Smoke Temperature Changes Animal (Specify): Exercise Exhaust Fumes Respiratory Infections Other (Specify): Pest Urine/Droppings Laughing/Crying WATCH for any of the following signs of an asthma episode TAKE THESE ACTIONS when you see any of the signs listed Difficulty walking or talking, whispers Stops playing or cannot participate in activities Complains of neck feeling funny or something stuck in their throat or frequent throat clearing Coughing frequently Appears anxious or restless Sits or stands hunched over Difficulty breathing, gasping, flared nostrils, audible wheezing sounds with breaths Lips or fingernails are blue or grey Call for at:__________________ Never leave student unattended Assist student to take own quick relief medicine if available If nurse is not available or if student does not improve after using own medicine – call 911 or call for emergency transportation in accordance with district policy Notify parent/guardian This plan was developed by the School Nurse (RN) below and reviewed with staff members. School Nurse Name: Date: School Nurse Signature: Copy to Parent (Optional) School Nurse Phone Contact:
ECPGenericAsthma0317.docx