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Brooklynfriends.infoservecm.com

Asthma Action Plan : 2012-2013 BFS school, overnight trips, spring, summer camp and field trips/any changes to treatment
requires a new/updated action plan.

*A Nebulizer is not as portable as an inhaler with a spacer/chamber and not manageable on class trips. Please fill in Yellow/Red ZONE in the event that the first 2 puffs of rescue medication does not improve the students symptoms. Orders need to be checked off or written in. General Information:
· Name _______________________________________________________
· Emergency contact ____________________________________________ Phone numbers __________________________________________
· Physician /Health Care Provider __________________________________ Phone numbers __________________________________________
· Physician Signature ____________________________________________ Date ____________________________________________________
SEVERITY CLASSIFICATION
TRIGGERS
EXERCISE
○ Exercise ○ Dust ○ Air pollution ________________________________________ 2. Exercise modifications: ___________________ Other ___________________________________ In case of Emergency (only available in school not trips) due to lack of inhaler*, you can choose from the following options:
Ventolin HFA (may be provided by school for shared usage) ○ May substitute stock Ventolin or generic Albuterol nebulizer solution
**____________________ HFA (to be provided by parent) ○ May not substitute stock Ventolin nor generic Albuterol nebulizer solution
**add medication name
*Please note: This option is only available if the student has been prescribed an inhaler, and either 1) forgotten the inhaler at home or 2) the inhaler is expired or
empty. This option to use a stock medication is not available on a school trip, a nurse must administer stock medications. Teachers may not administer
medications.they may assist self-medicated students.
The law encourages Self -Medication, see attached form. Preschoolers are able to
use an inhaler with a spacer/chamber and answer the 6 questions the NYS DOE requires for a student to be self- medicated.
Green Zone: Doing Well
Peak Flow Meter Personal Best = ________
Symptoms
Control Medications
Peak Flow Meter
More than 80% of personal best or ___or__
____
Yellow Zone: Getting Worse
Contact Physician if using quick relief more than 2 times per week.
Symptoms
Continue control medicines and add:
Peak Flow Meter
IF your symptoms (and peak flow, if used)
IF your symptoms (and peak flow, if used)
return to Green Zone after one hour of the
DO NOT return to the GREEN ZONE after
quick relief treatment, THEN
1 hour of the quick relief treatment, THEN
○ Take quick-relief medication every 4 ○ Change your long-term control medicines by ○ Change your long-term control medicines b ____________________________________ ○ Call your PCP within _____hours of modifying ○ Contact your physician for follow-up care your medication routine Red Zone: Medical Alert
Ambulance/Emergency Phone number _________________________________
Symptoms
Continue control medicines and add:
Peak Flow Meter
Go to the hospital or call for an ambulance if
Call an ambulance immediately if the following
○ Still in the red zone after 15 minutes danger signs are present
○ If you have not been able to reach your ○ Trouble walking/talking due to shortness of physician/health care provider for help: Parent/Guardian’s signature _____________________________________Date ___________________(Parent please keep copy)

Source: http://brooklynfriends.infoservecm.com/Customized/Uploads/Asthma%20Action%20Plan%201213.pdf

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