STUDENT ASTHMA/ANAPHYLAXIS ACTION PLAN
STUDENT NAME: DATE OF BIRTH:
(MONTH) (DAY) (YEAR)
Administer inhaler (2 inhalations)
15-30 minutes prior to exercise. (e.g., PE, recess, etc).
Albuterol HFA inhaler (Proventil, Ventolin, ProAir) Use inhaler with spacer/valved holding chamber Levalbuterol (Xopenex HFA) May carry & self-administer inhaler (MDI) Pirbuterol inhaler (Maxair) Other:
Give quick relief medication
when student experiences
when student experiences allergy
asthma symptoms, such as coughing, wheezing or tight chest.
symptoms, such as hives, difficulty breathing (chest or
neck “sucking in”), lips or fingernails turning blue, or
Albuterol HFA (Proventil, Ventolin, ProAir) 2 inhalations
Levalbuterol (Xopenex HFA) 2 inhalations
Use inhaler with spacer/valved holding chamber
May carry & self-administer inhaler (MDI)
Albuterol inhaled by nebulizer
.63 mg/3 mL 1.25 mg/3 mL 2.5 mg/3 ml
Adrenaclick® 0.3 mg Adrenaclick® 0.15 mg
Levalbuterol inhaled by nebulizer
0.31 mg/3 mL 0.63 mg/3 mL 1.25 mg/3 mL Other:
May carry & self-administer epinephrine
CLOSELY OBSERVE THE STUDENT AFTER
CALL 911 AFTER GIVING EPINEPHRINE &
GIVING QUICK RELIEF MEDICATION
CLOSELY OBSERVE THE STUDENT
If after 10 minutes:
EVEN if student improves, the student
Symptoms are improved, student may return to
should be observed for recurrent
classroom after notifying parent/guardian
symptoms of anaphylaxis in an emergency
No improvement in symptoms, repeat the treatment
If student does not improve or continues
If student continues to worsen, CALL 911 and
to worsen, INITIATE the Nebraska
INITIATE the Nebraska Schools’ Emergency
Schools’ Emergency Response to Life-
Response to Life-Threatening Asthma or
Threatening Asthma or Systemic Allergic
Systemic Allergic Reactions (Anaphylaxis)
Reactions (Anaphylaxis) Protocol
This student has a medical history of asthma and/or anaphylaxis and I have reviewed the use of the above-listed medication(s).
If medications are self-administered, the school staff MUST
(i.e. asthma triggers, allergens) Physician name
(please print) Phone
Physician signature Date
Reviewed by school nurse/nurse designee Date
STUDENT ASTHMA/ALLERGY/ANAPHYLAXIS INFORMATION
(THIS PAGE TO BE COMPLETED BY PARENT/GUARDIAN)
STUDENT NAME: AGE: GRADE:
SCHOOL: HOMEROOM TEACHER:
PARENT/GUARDIAN: PHONE(H) (W)
PARENT/GUARDIAN: PHONE(H) (W)
ALTERNATE EMERGENCY CONTACT: PHONE(H) (W)
KNOWN ASTHMA TRIGGERS:
Please check the boxes to identify what can cause an asthma episode for your student.
Exercise Respiratory/viral infections Odors/fumes/smoke Mold/mildew Pollens Animals/dander Dust/dust mites Grasses/trees Temperature/weather—humidity, cold air, etc.
Please check those which apply and describe what happens when your child eats or
comes into contact with the allergen.
Peanuts Tree Nuts Fish/shellfish
If your child has been been prescribed epinephrine (e.g. EpiPen) for an allergy, it is also necessary to provide epinephrine at
school. If your student requires a special diet to limit or eliminate foods, your school may ask your physician to complete the form “Medical Statement for Students Requiring Special Meals”.
Please list daily medications used at home and/or to be administered at school.
I understand that all medications to be administered at school must be provided by the parent/guardian.
Parent signature: Date:
Reviewed by school nurse/nurse designee: Date:
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