Microsoft word - asthma_emergencycare_planps 6.1.doc

To Be Completed by the Health Care Provider
San Francisco Unified School District
School Health Programs Department
1515 Quintara Street
San Francisco, CA 94116-1273
TEL: 415.242.2615 FAX: 415.242.2618
Age: ____ Date of Birth:___________________ School: ______________________________ Homeroom Teacher:_______________ Grade: _______ Room:___________
Parent/Caregiver Name: _________________________Phone (home)______________(cell):_____________ (work): ___________ Health Care Provider Treating Student for Asthma____________________________ Phone: __________________________ To provide assistance to a pupil experiencing asthma symptoms.
If you see or hear this
Actions to Take
1. Stay with student, speak softly, and stay calm 2. Keep person sitting upright and encourage slow deep breathing—in through the nose & out through puckered lips. 3. Give quick relief medication: (circle or write in)
If symptoms improve, may repeat in 4 hours. Other:____________________________________________ Location of med: __________________________________
Factors that may cause an
If symptoms continue, repeat in 5-10 minutes and have
asthma episode include: cold
helper call 911. May repeat with 3-4 puffs every 20min x3
until medical help arrives.
4. Have helper call parents/guardian/ and school nurse or Nurse mold, foods and/or OTHER: _____ *A completed and signed Medication Form must be on file at the school for ________________________________ each medication before medication can be administered at school. CALL 911 IF YOU SEE
• Breathing difficulty remains or worsens • Skin pulling in around collarbone and ribs • Student stopping play and not able to start activity again, due to breathing problems • Lips or fingernails turning (darkening) grey • Student having trouble talking or walking Administer CPR if breathing stops! Continue until paramedics arrive!
Does student need medicine before PE/ recess? ❏ No ❏ Yes Med Location ____________
As Needed? ❏ No ❏ Yes Always use before exercise? ❏ No ❏ Yes (school to complete)
Med: (circle or write in)Albuterol Inhaler – 2 puffs with spacer, 15-20 minutes before exercise
Other _______________________________________________________________________

I authorize school personnel to implement this Asthma Emergency Plan as described.
________________________________________________ _______________________________

Doy mi consentimiento para que las autoridades escolares tomen la acción apropiada para la seguridad y
bienestar de mi hijo/a. Doy mi consentimiento para que las autoridades escolares se comuniquen con el
médico de mi hijo/a, cuando sea necesario. ‰ Mi hijo/a no necesita los servicios.
________________________________________ _______________________________
Available @ http://portal.sfusd.edu/template/default.cfm?page=chief_dev.health.MedicalForms 5/05

Source: http://web.sfusd.edu/Services/translation/Lists/Translated%20Documents%20Archive/Attachments/27/Asthma_EmergencyCare_PlanPS%206.1-sp.pdf