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  • Inhaler and/or Asthma Action Plan

    The Bright School recognizes there are students who have allergies and/or asthma that may require the use of an inhaler. The following are guidelines for parents and students for the use of an inhaler during school hours and/or school sponsored activities.

    A list of all student allergies, use of inhaler, and/or asthma condition must be submitted to the school at the beginning of the school year.

    An Inhaler and/or Asthma Action Plan is to be filled out for each school year and is to include an updated picture of the student, please insert above.

    It is required that the parent supply the school with at least one inhaler to be stored in the front office. The student may keep an extra inhaler in his/her backpack. Spacers are encouraged.

    The inhaler may not be shared with other students.

    Per state law, and medication should be brought to school in original, pharmacy labeled container. The container shall display: student name, prescription number, medication name and dosage, administration route or other directions, date, licensed prescriber's name, and pharmacy name, address, and phone number.

    As age appropriate, students should be instructed in the use of their inhaler by their physician and parent on a yearly basis.

    Students participating in after school sports/activities are recommended to communicate with their coach/instructor concerning their medical condition and the possible need for use of their inhaler before, during, or after their activity.

    In the event of an extreme asthmatic attack in which the student's breathing does not respond to the inhaler, 911 (EMS service) will be called and the student will be transported to a local emergency room for further treatment and observation. Parents will be contacted as soon as possible and informed of student's transportation to an emergency facility.

  • Birth date
     / /
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Triggers: (Please mark all that apply)*
  • GREEN ZONE

  • No coughing, wheezing or difficulty breathing. Student can do usual activities but should avoid triggers. May need to pretreat before strenuous physical activity:
  • Exercise Pretreatment:
  • Exercise Pretreatment Activity
  • YELLOW ZONE: SICK- UNCONTROLLED ASTHMA

  • IF YOU SEE THIS:

    • Difficulty breathing
    • Wheezing
    • Frequent cough
    • Complains of chest tightness
    • Unable to tolerate regular activities but is still talking in complete sentences
  • DO THIS:

    • Stop physcial activity
    • Give quick relief medication (answer below)
    • Stay with student and maintain sitting position
    • Call parents/guardians and school nurse
    • Student may resume normal activities once feeling better
    • If student's symptoms do not improve in 10-15 minutes or worsen, follow RED ZONE plan
  • Give quick relief medication:
  • Quick Relief Medication Treatment: (select all that apply)
  • Student has life threatening allergy, refer to anaphylaxis plan if no improvement
  • !! If there is no quick relief inhaler at school:

    • Call parents/guardians to pick up student and/or bring inhaler/medication to school
    • Inform them that if they cannot get to school, 911 may be called
  • RED ZONE: EMERGENCY SITUATION

  • IF YOU SEE THIS:

    • Coughs constantly
    • Struggles or gasps for breath
    • Trouble talking (can speak only 3-5 words)
    • Skin of chest and/or neck pull in with breathing
    • Lips or fingernails are gray or blue
    • Level of consciousness
  • DO THIS IMMEDIATELY:

    • Give quick relief medication (answer below)
    • Refer to anaphylaxis plan if student has life threatening allergy.
    • Call 911 Inform attendant the reason for the call is asthma
    • Call parents/guardians and school nurse
    • Encourage student to take slower deeper breaths
    • Repeat quick relief medication if student not improving in 10-15 minutes (answer below)
    • Stay with student and remain calm
  • Give quick relief medication:
  • Quick Relief Medication Treatment: (select all that apply)
  • INSTRUCTIONS for QUICK RELIEF INHALER USE:
  • Format: (000) 000-0000.
  • I give permission for school personnel to share this information, follow this plan, administer medication and care for my child and, if necessary, contact our physician (Health Care Provider). I assume full repsonsibility for providing the school with prescribed medication and delivery/monitoring devices. I approve this Inhaler and/or Asthma Care Plan for my child.

  • Date
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  • Should be Empty: