Keystone Oaks School District 1000 Kelton Avenue Pittsburgh, PA 15216
School Asthma Action Plan

DIRECTIONS: Please complete this form in its entirety PARENTS: Complete Side 1
PHYSICIANS: Complete Side 2

Parent Name: 	Phone #: 	Emergency contact

other than parent: 	

Student Name: 	Teacher Name:

1. Triggers that might start an asthma episode for this student:

  Exercise  Animal Dander	  Cigarette smoke, strong odors	  Respiratory Infections

  Pollens	 Temperature Changes	  Foods	  Emotions (e.g. when upset)

  Molds	 Irritants (e.g. chalk dust)   Other 	

2. Control of the School Environment for asthma episode at school:

Environmental measures to control triggers at school 	

Pre-Medications (prior to exercise, choir, band, etc.) 	

Dietary Restrictions 	

3.	RoutineAsthma andAllergy Medication Schedule:
Medication Name
	Dose/Frequency
	When toAdminister At Home
	When toAdminister At School

				

4.	Peak Flow Monitoring Instructions if required:

5.	Field Trips: Asthma Medications and supplies must accompany student on all field trips.

a. Trained staff member will administer medication as necessary. Please list all required medications and

supplies: 	

6. Parent Consent for Management ofAsthma at School:

I, the parent or guardian of the above named student, request that this SchoolAsthmaAction Plan be used to guide asthma care for my child. I agree to:
1. Provide necessary supplies and equipment.

2. Notify the school nurse of any changes in the student’s health status.

3. Notify the school nurse and complete new consent for changes in orders from the student’s health care provider.
4. Authorize the school nurse to communicate with	, the primary care provider/specialist about asthma/allergy as needed.
5. School staff interacting directly with my child may be informed about his/her special needs while at school.

Parent/Legal Guardian Signature ___________________ ________________________ Date _______________	

Keystone Oaks School District 1000 Kelton Avenue Pittsburgh, PA 15216

School Asthma Quick Relief & Emergency Plan

PHYSICIAN: Please complete, sign and date

**Immediate action is required when the student exhibits any of the following signs of respiratory distress. Always treat symptoms even if a peak flow meter is not available.

Severe cough Chest tightness Wheezing

Shortness of Breath Turning blue
Rapid, labored breathing

Sucking in of the chest wall	Difficulty walking from breathing Shallow, rapid breathing	Difficulty talking from breathing Blueness of fingernails & Lips Decreased or loss of consciousness

Steps to Take During an Asthma Episode:

1. Give Emergency Asthma Medications As Listed Below:

Quick Relief Medications
	Dose/Frequency
	When to Administer
	
1.
			
2.

2. Contact Parents if 	

3. Under direction of school nurse, call 911 to activate EMS if the student has ANY of the following:

● Oxygen Saturation of 	

● Lips or fingernails are blue or gray

● Student is too short of breath to walk, talk or eat normally

● No relief from medication within 15-20 minutes with any of the following signs: *Chest and neck pulling in with breathing
*Child is hunching over *Child is struggling to breathe

Physician signature:_________________________________________  Date:_____________________