Student’s Name:                                                 Date of Birth:                      Date of Plan:                        

Usual Daily Medications:                                                                                       

                                                                                                                                                               

                                                                                                                                                               

Usual “Best” Peak Flow:                            

Yellow Zone:  If the child has difficulty breathing, wheezing, or peak flow is under            :

Give Albuterol MDI (2 puffs or nebulizer), then recheck Peak Flow in 10 minutes.

·         If Peak Flow improves and the child is breathing normally:                                            

o        the child may return to class. 

o        Recheck Peak Flow in 4 hours and notify parent.

·         If Peak Flow has not improved in 10 minutes, notify parent or our office.

 

Red Zone:  If the Peak Flow is under                      or the child is in distress:

·         Give Albuterol MDI 2 puffs or nebulizer.

·         Call parent, our office, or 911 immediately.

q               This child has been instructed in the proper way to use his/her medications.  In my professional opinion, he/she should be allowed to carry and use the medications by him/herself. q               This child should receive his medications from the school nurse as needed.

                                                                                                                                         

Physician                                                                                                                             Date

                                                                                                                                         

Parent                                                                                                                                  Date