asthma action plan / medication authorization form
Asthma Action Plan/Medication Authorization Form For all children with asthmaMecklenburg County Health Dept. Student Name ______________________________ CMS Student ID# ____________________________________ School/Year ______________________________ Grade/Teacher ______________________________________ Parent/Guardian ______________________ Contact Number (H) ______________Cell______________ Work___________ Physician’s Name_____________________ Physician Phone Number _____________________ Fax ____________________
1. NO SMOKING in your home or car, even if your child is not with you. 2. Always use a spacer with inhalers (MDIs). 3. Shake inhaler before every spray (puff). 4. Remove, control and stay away from known triggers in your child’s environment. 5. Clean plastic part of inhaler weekly using package directions. 6. Prime inhaler after opening and before use if not used in more than two weeks. Proair-three puffs, all others four puffs. Child’s triggers are: (circle or check all that apply to your child) Respiratory infections or flu
allergies_________________________________
GREEN ZONE – ALL CLEAR – GO! USE CONTROLLER MEDICINES ASTHMA IS WELL CONTROLLED No controller medicine needed at this time You should have: Medicine Method How Much How often
__________________ _________ ________ ______times per day
__________________ _________ ________ ______times per day
No waking up at night because of asthma __________________ _________ ________ ________________
No problems with play because of asthma __________________ _________ _________ ________________ Peak flow number from _____ to _____ 15 minutes before exercise use __________ puffs (inhaled) _____________ ONE – CAUTION! – TAKE ACTION TAKE QUICK RELIEF MEDICINE ASTHMA GETTING WORSE Continue to use green zone daily medicines and add: You may have: Medicine Method How much How often
Albuterol/Xopenex inhaled ____puffs OR ____vial Every ___hours prn
Also take:
Chest Tightness ___________________ _____________ ______________ ____________
Coughing at night If yellow zone symptoms continue for 24 hours or child needs extra rescue
Peak flow number from _____ to _____ medicine more than 2 times per week, call your child’s doctor. RED ZONE – STOP! – GET HELP NOW! TAKE QUICK RELIEF MEDICINE THIS IS AN EMERGENCY! You may have:
Quick relief medicine that is not helping
Continue to use green zone medicines and do the following:
_____ puffs or 1 vial Albuterol/Xopenex inhaled every
CALL DOCTOR NOW! If you cannot reach doctor, CALL 911
Chest and neck pulled in with each breath
or go directly to the EMERGENCY ROOM OrPeak flow less than ______________ DO NOT WAIT! Physician Signature________________________________________________ Date________________________________ Parent/Guardian Signature_________________________________________ Date________________________________ School Health Nurse Signature ______________________________________ Date________________________________
Student self carries inhaler Y/N Inhaler in the Health Room Y/N Inhaler in classroom Y/N CI 45 3/09 AUTHORIZATION FOR SELF-MEDICATION BY CMS STUDENTS
Student's Name__________________________________________ Birthdate______________________ Medication___________________________________for ____________________________________ Eligibility: In accordance with CMS Policy JLCD, Administering Medications to Students, and its accompanying regulation, JLCD-R, only students who meet the following descriptions may possess and self-administer medications: (1) Students with special medical needs such as asthma and/or severe allergies or who are subject to anaphylactic reactions and may require emergency medications (i.e., asthma inhaler or epinephrine auto-injector [“Epi-pen]); and (2) Students who require frequent administrations of non-prescription medications or prescription medications that are not controlled substances. - - - - - - - - - - - - - - - - - - - - - - - - - - - Healthcare Provider: The student named above has (1) asthma or an allergy that could result in an anaphylactic reaction and may require emergency medications; or (2) a condition that requires frequent administration of a prescription or non-prescription medication. The medication is not a controlled substance. This student is capable of, has been instructed on the procedures for and has demonstrated the skill to self-administer this medication as directed on page 1 of this form. Please allow him/her to self-administer the medication during school hours and as otherwise indicated on page 1 of this form. This
will not require adult supervision while taking this medication.
Physician signature/date____________________________________________
Parent/Guardian: I give consent to the Charlotte-Mecklenburg Schools to allow my child to self-administer this medication at school. I understand that my child and I assume responsibility for the proper use and safekeeping of this medication. If the medication that is prescribed for my child is for the treatment of asthma or anaphylactic reactions, I agree to provide a supplementary supply of the medication that will be kept by the school in a location to which my child has immediate access. I absolve the Charlotte-Mecklenburg Board of Education and their agents and employees from any and all liability whatsoever that may result from my child possessing or taking this medication at school. I further consent for the information about my child included on pages 1 and 2 of this form to be shared with appropriate school staff as necessary for the safety of my child. Parent signature/date ______________________________________________ Student: I am capable of taking this medication as recommended and accept this responsibility. I will keep it secure at all times and will not share it with others. I understand that I will be subject to discipline under the Student Code of Conduct if I abuse the privilege of being allowed to self-medicate while at school or school sponsored activities. Unless the medication is prescribed for the treatment of asthma or anaphylactic reactions, I understand that I will lose the privilege of self-administering my medication if I do not follow these rules. Student signature/date _______________________________________________
School Nurse: I have reviewed this request and acknowledge that this student has demonstrated the skill level to self- administer this medication. I have informed this student that he or she must tell an appropriate staff member whenever he or she has used the medication at school. Nurse signature/date __________________________________________________
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Asthma Action Plan/Medication Authorization Form