Liberty School District
29818 S. North Pine Creek
Spangle, WA 99031
(509)245-3211
(509)245-3530 Fax
ASTHMA / REACTIVE AIRWAY DISEASE
LICENSED HEALTHCARE PROVIDER ORDERS
EMERGENCY CARE PLAN / IHP / 504 PLAN (on reverse side)
Orders/care plan valid from August 1, 2010 through July 31, 2011
Student Name:
Birth Date:
Grade:
Allergies:
Parent/Guardian:
Parent/Guardian:
Other Emergency Contact:
Preferred Hospital:
P.E. Days/Times:
Student’s Triggers:
Normal Peak Flow:
Home Phone #:
Teacher:
Other Health Concerns:
Work Phone:
Work Phone:
Work Phone:
Phone:
Bus #:
Cell Phone:
Cell Phone:
Cell Phone:
Routine Medications:
DANGER ZONE:
MEDICATION ORDERS
(Signed by a Licensed Healthcare Provider with Prescriptive Authority)
Inhaled Medication: ______________________________________ per Metered Dose Inhaler Nebulizer
Dose: _______________ puffs
 PRN every _________________ hours
 Routinely at ______________________________________
 May repeat dose in ________minutes/hours if symptoms not relieved by first dose. Notify parent.
 May repeat dose in ________minutes/hours if symptoms reoccur before next dose is due. Notify parent.
 This student has severe asthma or a life-threatening allergy which may require additional treatment.
 Give Epi-Pen after any witnessed or suspected allergen ingestion/contact, OR if student showing any allergy symptoms.
Epinephrine: _______Epi-Pen, Jr. (0.15mg) injection
_______ Epi-Pen (0.3mg) injection
 May repeat Epi-Pen in 10 minutes if symptoms not relieved.
*****A student may NOT remain at school after an Epi-Pen is given.*****
As soon as the Epi-Pen is given: □ CALL 911 IMMEDIATELY!! Have EMS transport to hospital.
□ CALL 911 IMMEDIATELY!! A parent/guardian must pick up the student for transport.
□ Follow Epi-Pen with Antihistamine: _________________________________
Dose: __________________ mg/ml.
 Yes  No
 Yes  No
 Yes  No
Frequency: Every ______ hours.
This student has been instructed in the proper use/administration of their metered dose Epi-Pen/inhaler.
This student has demonstrated the proper use/administration of their metered dose Epi-Pen/inhaler to
me or a trained member of my staff.
This student has my permission to carry their own Epi-Pen/inhaler.
My signature signifies that I have read and approved the Emergency Care Plan (on reverse side). Date: ________
Physician Signature: ____________________________________________
Phone Number: _____________
Print Physician Name: ___________________________________________
Fax Number: ________________
PARENT/GUARDIAN CONSENT
My student may carry their own emergency medications. □ YES
□ NO
My signature indicates my involvement in and agreement with the plan and information provided. I understand that if my student
receives any emergency medication, I may be required to pick them up from school and be responsible for monitoring them for signs of
further breathing difficulty or allergic reaction. I understand that if I do not wish to provide back-up medications for the school, my
student will be required to demonstrate to the bus driver or school secretary (if driving or driven to school) that they have their
medications on their persons as they board the bus or arrive at school. If they do not have their emergency medications with them, I
understand that I will be notified to pick them up from school or bring their emergency medications to school for them. I understand
that my student athlete will also have to demonstrate to their coach that they are carrying their emergency medications on their persons
in order to participate in athletics.
Parent Signature: __________________________________________
Date: __________
School Nurse Signature: _____________________________________
Date: ___________
ASTHMA / REACTIVE AIRWAY DISEASE EMERGENCY CARE PLAN / IHP / 504 PLAN
Student Name:
Grade:
Teacher:
Emergency medications are located in:  _________ Medication Cupboard
 Student’s Backpack
 Student’s Locker #: ________
Combination: __________________________
 Student’s Bus#: ___________
 Student’s Athletic Coach: ______________________
Medications expire: Inhaler ____________________________
Epi-Pen: _____________________
Students with life threatening allergies AND asthma have an increased risk of death with an allergic reaction.
Medical Problem: Asthma is an inflammatory disease of the respiratory tract. It is a chronic condition with ongoing tightening (bronchospasm) and inflammation of the airways causing episodes of breathing difficulty such as wheezing, chest tightness or persistent coughing.
IF YOU SEE THIS:
DO THIS:
___________’s normal symptoms are in bold type.
EARLY SIGNS: - GO
Shortness of breath.
Tickle or itch in throat.
Beginning cough.
Headache.
Wheezing.
Agitation or behavior changes.
Fatigue.
Agitation
Complains of difficulty breathing.
MODERATE SIGNS:: - CAUTION
Shortness of breath.
Unusual breath sounds.
Increasing anxiety or fear.
Shoulders hunched over.
Vomiting.
Chest tightness.
Sweating.
Nostrils flaring.
Complains of difficulty breathing.
No improvement of symptoms within 15 minutes
after inhaler administration.
- IF _____________ COMPLAINS OF DIFFICULTY BREATHING
AN ADULT MUST ACCOMPANY ___ TO THE OFFICE
IMMEDIATELY, OR CALL THE OFFICE FOR HELP.
NEVER SEND ________________ ANYWHERE ALONE!!!.
- Give emergency medications as listed below.
1.)
- ________________ may return to class or normal activity if all
breathing difficulty is gone.
- If breathing difficulty continues after 15 minutes, repeat above
medication.
- Notify the school nurse immediately at extension 2211.
- Have ____________ sit up with ___ shoulders relaxed for 10-15
minutes after any medications are given.
- Have ___________ breathe slowly – in through ___ nose and out
through pursed lips.
- Notify parent to pick up __________ if symptoms persist
for more than 15 minutes after medications are given.
SEVERE SIGNS: - DANGER
- CALL 911 IMMEDIATELY!!!
Rapid, labored breathing > 30 times/minute.
Increased heart rate > 120 beats/minute.
- An adult trained in CPR is to stay with _________ until EMS
“Pulling in” of chest or neck muscles with breathing.
Cannot speak a full sentence without taking a breath.
Child is hunched over struggling to breathe.
Blue or gray lips, nail beds or skin color.
before having EMS transport ______________ to the hospital.
- IF __________HAS A LIFE THREATENING ALLERGY AND
ASTHMA AND CONTINUES TO COMPLAIN OF DIFFICULTY
BREATHING OR DEVELOPS A RASH – TREAT THE
arrives. Notify the parent. DO NOT wait for the parent to arrive
No improvement of symptoms within 15 minutes of
inhaler administration.
Disorientation or loss of consciousness.
BREATHING OR HEARTBEAT STOPS.
ALLERGY TOO!!!
- Give emergency medications as listed below:
1.) As soon as the Epi-Pen is given – CALL 911 and have
them launch the helicopter.
- CALL 911 IMMEDIATELY!!! Begin rescue breathing and
CPR until relieved by EMS.