Download ASTHMAcareplan page1 - Masconomet Regional School District

MASCONOMET REGIONAL SCHOOL
HEALTH SERVICES
20 ENDICOTT ROAD
BOXFORD, MASSACHUSETTS 01921
(978) 887-2323
HS Nurse ext. 6116 Fax #978 887 7243
MS Nurse ext. 6125 Fax #978 887 1991
ASTHMA CAREPLAN 2016-2017
Student ______________________________________Date of Birth __________Grade_____
Date of Diagnosis______________How often do the asthma attacks occur?_________________Date of Last Asthma attack____
Has student been treated in the hospital for asthma in the past year?
Asthma severity:
□ mild intermittent
□ mild persistent
□ No □Yes
□ moderate persistent
When ___________________________
□ severe persistent
Is a peak flow meter used? □ No □Yes Best flow rate is _____________________
CHECK THE CONDITIONS THAT USUALLY BRING ON THIS STUDENT’S ASTHMA ATTACK:
respiratory infection ______________________ exposure to cold air _______________ emotional stress ______________________
exercise( e.g. after running, etc.) ________________________________________________________________________________
odors (e.g. perfume, smoke, etc) ________________________________________________________________________________
allergic reaction to (e.g. mold, animals, etc.) _______________________________________________________________________
other (describe) _____________________________________________________________________________________________
CHECK THE SIGNS THAT ARE USUALLY PRESENT IN THIS STUDENT’S ASTHMA ATTACK:
coughing □ wheezing □ shortness of breath □ feeling frightened □ bluish color of skin/nails
□ unable to speak sentence without taking a breath □ other (describe) __________________________________________________
Special needs, activity restrictions/ adaptations or protective equipment needed at school?
No
Yes (describe) _______________
______________________________________________________________________________________________________________
THE USUAL PROCEDURE FOLLOWED AT SCHOOL INCLUDES:
1. Allow student to use his/her prescribed asthma medication with assistance given as needed.
2. Encourage student’s relaxation (e.g. slow, deep breathing, sipping warm fluids).
3. Stay with student; monitor for symptoms.
Students are encouraged to carry their own inhalers and it is recommended that a spare inhaler be kept in the nurse’s office. I give
permission for my child to carry the inhaler listed in the medications table on the reverse side of this form.
We understand that he/she must follow the rules below:
a) he/she must demonstrate the correct use of the inhaler to the school nurse
b)
he/she agrees never share the inhaler with another student
c)
he/she agrees that after two puffs, if there is not marked improvement, he/she will go the nurse’s office immediately
I give permission for the school nurse to obtain written information or to speak with my student’s doctor regarding this diagnosis and to
share with necessary school personnel information included in this document Yes___ No___
I give permission for the school nurse or his/her delegated personnel to administer the medications listed on the reverse side at school
or on school related events. Yes___ No___
This student has permission to self-administer the medications at school or on school related events, if the school nurse deems it
appropriate. Yes___ No___
Parent Signature _________________________________________________________________Date __________
School Nurse Signature ____________________________________________________________Date __________
EMERGENCY CONTACTS:
Name:__________________________Relation:_____________Phone(s)___________________
Name__________________________ Relation______________Phone(s)__________________
Masconomet has a policy regarding taking medications at school. Please call the school nurse for direction.
Tests and activity restrictions occurring during school hours require written direction from your child’s doctor.
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Revised 7/13