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Microsoft word - actionplanjan2005.doc

ASTHMA ACTION PLAN
(To be updated at least annually and as needed)
For children in childcare, kindergarten
and family day care
Instructions
1. To be completed by parents in consultation with their child’s doctor. 2. Parents should inform their child’s childcare service, kindergarten or family day care immediately if there are any changes 3. Please tick the appropriate box or print your responses in the blank spaces where indicated (for some questions you may The information on this Plan is confidential. All staff that care for your child will have access to this information. It will only be distributed to them to provide safe asthma management for your child. The service will only disclose this information to others with your consent if it is to be used elsewhere. ………………………. ………………………… Sex: M F Date of birth: .…./.…./…. PERSONAL DETAILS
Parent’s Name: ……………………………………. Telephone: (H) ………………………. (W) …………………… (M) ………………………. Emergency contact (e.g. parent/guardian): ………………………………………………… Relationship: ………………………………………. Emergency contact telephone: (H) ………………………. (W) ……………………………. Doctor: ……………………………………. Telephone: …………………………………… Ambulance subscriber: Yes No Subscriber number: …………………………. USUAL ASTHMA ACTION PLAN
Usual signs of child’s asthma Signs of child’s asthma worsening
What triggers the child’s asthma?
Does the child tell the carer when they need medication? Does the child take any asthma medication before exercise/play? MEDICATION REQUIREMENTS USUALLY TAKEN IN CARE
(Include relievers, preventers, symptom controllers and medication before exercise).
Name of Medication
Method (e.g. puffer & spacer)
When and how much?
The Asthma Foundation of Victoria January 2006 ASTHMA FIRST AID PLAN
Please tick your preferred Asthma First Aid Plan 4 STEP ASTHMA FIRST AID PLAN
1. Sit the child down and remain calm to reassure them. Do not leave the child alone. 2. Without delay shake a blue reliever puffer (Airomir, Asmol, Epaq or Ventolin) and give 4 separate puffs through a spacer* (use the puffer alone if a spacer is not available). Use one puff at a time and ask the child to take 4 breaths from the spacer after each puff. 3. Wait 4 minutes. If there is no improvement, repeat step 2. 4. If still no improvement after a further 4 minutes – call an ambulance immediately (dial 000) and state that the child is having an asthma attack. Continuously repeat steps 2 and 3 while waiting for the ambulance. If the child’s condition suddenly deteriorates or if at any time you are concerned — call an
ambulance immediately.
*Children under five years of age may need to use a facemask attached to the spacer. CHILD’S EMERGENCY TREATMENT APPROVED BY YOUR DOCTOR
If the child’s condition suddenly deteriorates or if at any time you are concerned — call an
ambulance immediately.
• In the event of an asthma attack, I agree to my child receiving the treatment described above. I authorise children’s services staff to assist my child with taking asthma medication should he/she require help. I will notify you in writing if there are any changes to these instructions. I agree to pay all expenses incurred for any medical treatment deemed necessary. Please notify me if my child has received asthma first aid. Parent’s/Guardian’s Signature: ___________________________ Date___/___/___ Doctor’s Signature: ____________________________________ Date___/___/___ For further information please contact The Asthma Foundation of Victoria on (03) 9326 7088, toll free 1800 645 130, or visit our website www.asthma.org.au The Asthma Foundation of Victoria January 2006

Source: http://cpca.com.au/s1/yabc/Asthma_Action_Plan_3.pdf

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