6 Alabama State Department of Education Individualized Health Care Plan Student Name: Asthma Individualized Healthcare Plan SECTION WT: [students oe ae DOB Any Known Allergies - a Bus (check one) OES — Bas a — School Nurse: Pager # Medication taken at home: (please list) Contacts | Mother Home # Work # Pager/Cell # | Father | Home# | Work # Pager/Cell # - Guardian/Custodian Home# Work # PagerCell # | Home Address City # 7 Zip “Emergency Contact (Relationship) “Home# Workt Physician Phone # Faxt - Physician Address 7 “City Zip a Date Special Notes@ Alabama State Department of Education © Individualized Health Care Plan Student Name: ‘School Year: Asthma Individualized Healthcare Plan SECTION i: Emergency Action Plan IF YOU SEE THI ‘Coughing, Wheezing Prolonged Expiration ‘Tightness in Chest fi Gasping for Air Change in Color of Skin (Pale or Blue) 2 DO THIS WHEN MEDICATION DO THIS WHEN MEDICATION AVAILABLE... ROUAy sTIARLESS *Med/Dose:___ Have student sit in calm, cool 1. Route: [ Inhaler** 1 Nebulizer environment (if possible). 2. Observe student for change in condition 3. Allow student to return to class if symptoms Relieved/Improved after Have student sit upright with hands on knees (arms straight). medication. _ - Tf no change in symotoms after 15 minutes of medicatio Encourage purse-lip breathing (slowly *Med/Dose: L inhale through nose and exhale through 1. Route: Cl Inhaler** CO) Nebulizer pursed-lps). 2. Call parent about student using medication x 2 3. Have student maintain sitting position 4, Limited physical activity. If no improvement in symptoms after second dose of m contact parent after second dose is administered... 1, Cail 9-1-1 (Continue trying emergency contacts) 2. Encourage slow deep breathing, rest | 3.__Have student maintain sitting posi Student complains, is hunched over, has difficulty breathing, is unable to speak, | uses neck/shoulder muscles to assist in breathing effort, lips and/or nail beds are blue in color 1. Call 9-1-1 2. Call parent/guardian 3. Rest, reassurance, calm slow deep breathing tion and unable to fstudent becomes unconscious... If no improvement... 1, Call 9-1-1 1, Call parentvemergeney contact, 2. Call parenVemergency contact L% catg-ta + ALL MEDICATIONS GIVEN AT SCHOOL REQUIRE A SCHOOL MEDICATION PRESCRIBER/PARENT AUTHORIZATION SIGNED BY THE ‘PRESCRIBER ~ SEE PAGE WS ‘Proper technique fr using inhaler: Have student sit upright. Remove cap; old Inhaler upright. Shake well. Tilt head slighty Back, and have student breath ‘uz, Postion inhaler In or near mouth or use spacer. Have student take a deep breath; press dawn on inhaler while student aking a breath Count 10 while ‘Student holds breath. School Nurse Use Only "cath Expiration > i Medication Date | SelCarry? Location of Medication© Alabama State Department of Education © Individualized Health Care Plan Student Name: School Year: Asthma Individualized Healthcare Plan SECTION IL ASTHMA is a chronic lung disease, which is characterized by attacks of breathing difficulty. It is caused by spasms of the muscles in the walls ofthe sir passages tothe lungs. It is nat contagious and tends to run in families. Asthma can be aggravated by allergy to pollen ‘or dust, viral illness, cold, emotions, or exercise. There is no cure but asthma can be controlled with proper diagnosis and management. ‘Treatment consists of avoiding knowin triggers, recognizing early symptoms, monitoring with a peak flow meter, and medication to reduce ‘or prevent symptoms. Some children who are allergic to specific substances may benefit ftom desensitization shots. AVOID EXPOSURE TO KNOWN TRIGGERS (please list):” 2 DICATIONS AT SCHOO! POTENTIAL SIDE EFFECTS: Albuterol Inhaler: COW/SPAGER_ COW/O SPACER Ti Tremors Rapid Heart Rate On-Person Cyes ONO CO Headache ‘Authorized to Self-Administer. —-CIYES LINO Oi Dizziness Nebulizer Treatment CIES CINO Dry Mouth & Throat Other: Other: Type Here MEDICATIONS AT HOME: POTENTIAL SIDE EFFECTS: CLASSROOM PHYSICAL EDUCATION: Tr Avoid al Aerosols Ti Student Roa ies Following Limitations Ci Avoid cleaning substances with strong odors 1 Other (please speci Encourage Participation, but Do Not Force 11 Do Not lenore Student's Symptoms. Contact schoo! murse if student develops symptoms of acute asthma | (Other: «episode. Contact school nurse ifstudent develops symptoms of acute asthma _ | episode FIELD TRIPS: BUS TRANSPORTATION: 7 Student IS authorized to keep on person & self i Student IS authorized to keep on person & self-administer ‘administer inhaler: inhaler. Student will keep inhaler on person at allies. 1D Student will keep inhaler on person tall times. Gi Student will notify teacher/sponsor inthe event inhaler isnot | [1 student exhibits signs or symptoms of distress, after using relieving symptoms. inhaler bus driver wil activate 911, notify paren, and If student exhibits signs or symptoms of distress, administration. tecacher/sponsor wil ative 911, notify parent, & Admin | _ _ Student IS NOT authorized to keep on person & self- GF Student is NOT authorized to keep inhaler on person & administer inhaler: self-administer inhaler. i Nurse or Medication Assistant will accompany tip with Cl tfstudent exhibits signs or symptoms of respiratory distress, ‘medication & orders on person bus driver will activate 911, notify parent, and administration. Student will have ready access to Nurse or Medication 0 Othe Assistant for duration of trip © Parent will accompany trip _ EMERGENCY DRILLS & SCHOOL CRISIS EVENTS: | BEFORE/AFTER SCHOOL EVENTS: Tin Crisis Event Follow School Safety Plan Notes and Comments: - Ci School Nurse or designated personnel will deliver ~ ‘medications to designated location per crisis plan. Cif authorized, student will keep inhaler on person Student requites mobility assistance = YES (JNO LI YES describe plan: Type Here |@ Alabama State Department of Education Individualized Health Care Plan Student Name: ~ Written Notes/Addendum to Plan of Care Date | Notes ‘Nurses Signature ‘Signature of Parent or Guardian Date Signature of School Nurse Date@ Alabama State Department of Education © Individualized Health Care Plan Student Name: ‘School Year: SCHOOL MEDICATION PRESCRIBER/PARENT AUTHORIZATION ‘STUDENT INFORMATION Students Ni Sehool: Dateof Birth: Age: Grade: Teacher, (0 No known drug allergies-—if drug allergies list: Wien pounds PRESCRIBER AUTHORIZATION (To be completed by licensed healineare provider) ‘Medication Name Dosage: Route: requeney/Time() tobe giv Start Date: Stop Date:_/_/— ‘Reason fr taking medication Potential sie eft contrandicationsadverse rections: Treatment order the event of en adverse reaction: = SPECIAL. INSTRUCTIONS [nthe mediestion a conrolled substance? Ye oo Nooo Js self-medication permitted end reeommended? Yoo No Tees" Thereby afr this stadent has been instructed ‘On proper sel-adinstation ofthe prescribe medication. ‘Do yo reormend this meication be kept “on person” by student Yes No oo Printed Name of Licensed Healthare Provider: Signature of Licensed Healtheare Provider: = if PARENT AUTHORIZATION [authorize the School Nurse the registered nurse (RN) of icensed practical muse (LPN) 1 adiniste orto delegate to unlicensed school personnel the task of asiting ty child in aking the above medication in accordance with te administrative code pactice ules. {understand tht additional parenprescriber signed statements will be osesary ifthe dosege of mediation ie changed. Llso authorize the School Nurse al withthe prescribe or pharmacist should w question come up with he mediation. reser tlon Medication must be registered with School Nurse or trained Medication Assistants. Prescription mediation must be propery labeled wit student's ‘name, peserber's name, name of mization, dosage, time intervals, rout of administration and the dt of rugs expiration when appropiate ‘Over the Counter Medication mast be registered wit the School Nuse or Trained Medication Assistant, OTC's inthe original, unopened and sealed container, Lest Education Agency Policy for OTC medication tbe fellowes: Parcots(Guardian’s Signature: Lt Phone (DMINISTRATION AUTHORIZATION 0 be com ted ONLY if student | [authorize and recommend self-medication by my child forthe above medication. 1 also afi that else as been instructed inthe proper sl-administation of the preseribed mediation by hisheratending physician, 1 shall indemnify and hold hale the schol, the eget ofthe school, an the Teel board of education against ‘any claims that may rise eating to my child's st-adminsraton of prescribed medieons). |_1___ Phone: ( Signature of Parent: Date:a Alabama State Department of Education © Individualized Health Care Plan Student Name: ‘School Year Communication of the Individualized Health Care Plan CO Check this Box if Read Receipt is used to communicate Individualized Health Care Plan to staff. * Nurse to attach Read Receipt document to this packet. Check this box if staff receives and signs below for Individualized Health Care Plan. Thave read and understand this student's Individualized Healthcare Plan, and have printed a copy to be maintained in my confidential folder/binder of instructions for substitute teachers. Ihave been given the opportunity to ask questions. Lunderstand my role in addressing this students medical needs. Tam aware the school nurse is available to help clarify any future concerns ‘Employee Name ‘Employee Signature Position Date |