State of Hawaii Department of Education

EMERGENCY ACTION PLAN for Severe Asthma

School / SY / - / Grade/Room: / Date:
Emergency Contacts:
Mother/Guardian / (W) / (cell) / (H)
Father/Guardian / (W) / (cell) / (H)
Alternate Emergency Phone Contact
Name / Relationship / Phone #
Physician Treating Student for Asthma: / Ph: / Fax:
Other Physician: / Ph: / Fax:
Student Name: / Date of Birth:

Triggers: Identify the things that may start or trigger an asthma episode (Circle and/or writing in all that apply):

Exercise Strong odors or fumes Respiratory infections

Chalk dust Changes in temperature Carpeting

Animal fur/dander Pollens Molds Cold air

**Food: / Other:

**Insect bites/stings

(**Does student have Epi-pen? Yes No)

Carries own Inhaler (Act 19) / Inhaler in Health Room

Significant Information:

Current Medications:
Cough / Shortness of Breath / Chest Tightness / Wheeze

Usual Asthma Symptoms:

Other:

·  If a student has any of the following symptoms: Chest tightness, difficulty breathing, wheezing, excessive coughing, and shortness of breath:

1.  Stop activity and help student to a sitting position

2.  Stay calm, reassure student

3.  Assist student with the use of their inhaler

4.  Student to be escorted to Health Room or call for immediate assistance. Never send student to HR alone.

Emergency Plan

·  Follow the Request for Administration of Medication (DOE/SH 36) – Emergency Rescue Medications. Contact parent/guardian to pick up student ASAP. If unable to reach parent/guardian, notify principal/health designee.

ü  Call 911 - for ANY of these:

ü  No improvement - 15-20 minutes after treatment with medication.

ü  Student is having trouble with walking or talking

ü  Student is struggling to breathe

ü  Student’s neck and/or chest, and ribs pulled in with breathing

ü  Student’s lips are blue, and/or

ü  Student must hunch over to breathe

05/2012