Original to school nurse (IHR); copies to appropriate staff. Rev. 10/2016

Nash-Rocky Mount Public Schools Student Health Services

Nash-Rocky Mount Public Schools Student Health Services

Asthma Action Plan Student has Rescue Inhaler at School

(Doctor’s orders not received)

Student DOB Grade School

Parent/Guardian

# Teachers

Allow student to self-medicate and call parent. If Nurse is on campus, send to nurse for assistance and assessment.

If any symptom is present: Step 1 Albuterol Inhaler 2 puffs or 4 puffs, every 20 minutes for up to 1 hour ■ Coughing Nebulizer - 1 treatment ■ Wheezing Other, describe ■ Short of breath Step 2 Call school nurse, if symptoms do not improve/parent, if nurse is not on campus. ■ Tightness in chest ■ Can do some, but not all usual activities ■ Can’t play/exercise easily

If any symptom is present: Step 1 Use NOW! Albuterol Inhaler 4 puffs or 6puffs or Nebulizer ■ Very short of breath Other, describe ■ Breathing is very difficult or very fast Step 2 Call 9-1-1. Student must go to the Emergency Room immediately. ■ Using neck or stomach muscles to breathe ■ Nostrils are opening wide to breathe Signs of extreme danger: ■ Trouble walking or talking ■ Lips or fingernails are blue

Yellow Zone: Caution! Asthma Getting Worse

Do This: Use rescue medication. Monitor symptoms. If no improvement, call school nurse/parent.

Red Zone: Emergency! Do This: Get help fast! Call 9-1-1.

To be completed by school nurse Yes No Orders received from doctor for staff to assist student. Yes No Student demonstrates competency in using inhaler. School nurse: Date:

Call healthcare provider if: 1) Symptoms worsen. 2) Albuterol needed more often than every 4 hours. 3) Albuterol needed every 4 hours for more than 1 day.

1. Take the cap off the inhaler and shake well before each

puff.

2. Breathe out to empty the lungs as much as possible.

3. Place the mouthpiece of the inhaler in your mouth and

make a tight seal.

4. Begin to breathe in slowly through your mouth and press

down on the inhaler one time. Continue to breathe in

slowly as deep as you can.

5. Hold your breath while you count to 10 slowly. (This allows

the medicine to reach deep into your lungs.)

6. Repeat second puff after waiting 1-2 minutes.

1. Take the cap off the inhaler and shake well before each puff.

Attach the spacer to the inhaler.

2. Breathe out to empty the lungs as much as possible.

3. Place the mouthpiece of the spacer to your mouth with a tight

seal. If spacer has a mask; press mask to make a seal around

the mouth.

4. Press down on the inhaler which will put one puff of medicine

into the spacer. Inhale slowly and deeply.

5. Hold your breath for 10 seconds. (This allows the medicine to

reach deep into your lungs.)

6. May breathe in and out slowly 3-5 times instead of holding

breath for 10 seconds.

7. Repeat 2nd puff after waiting 1-2 minutes.

Inhaler without spacer

School YR

Inhaler with spacer/mask