Special Care Plan for a Child with Asthma
Child's Name:________________________________________ Date of Birth:__________________
Parent(s) or Guardian(s) Name:_____________________________________________________________
Emergency phone numbers: Mother__________________________
Father__________________________
(see emergency contact information for alternate contacts if parents are unavailable)
Primary health provider's name:____________________
Emergency Phone:____________________
Asthma specialist's name (if any):_____________________
Emergency Phone:____________________
Known triggers for this child's asthma (circle all that apply):
colds mold exercise tree pollens
house dust strong odors grass flowers
excitement weather changes animals smoke
foods (specify):___________________________________________ room deodorizers
other (specify):_______________________________________________________________
Activities for which this child has needed special attention in the past (circle all that apply)
outdoors indoors
field trip to see animals kerosene/wood stove heated rooms
running hard art projects with chalk, glues, fumes
gardening sitting on carpets
jumping in leaves pet care
outdoors on cold or windy days recent pesticides application in facility
playing in freshly cut grass painting or renovation in facility
other (specify):___________________________________________________________
Can this child use a
flowmeter to monitor need for medication in child care? NO YES
personal best reading:__________ reading to give extra dose of medicine:______________
reading to get medical help:________________________
How often has this child needed urgent care from a doctor for an attack of asthma:
in the past 12 months?__________ in the past 3 months?____________________________
Typical signs and symptoms of the child's asthma episodes (circle all that apply):
fatigue face red, pale or swollen grunting
breathing faster wheezing sucking in chest/neck
restlessness,agitation dark circles under eyes persistent coughing
complaints of chest pain/tightness gray or blue lips or fingernails
flaring nostrils, mouth open (panting) difficulty playing, eating, drinking, talking
1.
Notify parents immediately if emergency medication is required.
2.
Get emergency medical help if.
- the child does not improve 15 minutes after treatment and family cannot be reached
- after receiving a treatment for wheezing, the child:
*is working hard to breathe or grunting *won't play
*is breathing fast at rest (>50/min) *has gray or blue lips or fingernails
*has trouble walking or talking *cries more softly and briefly
*has nostrils open wider than usual *is hunched over to breathe
*has sucking in of skin (chest or neck) with breathing *is extremely agitated or sleepy
3. Child's doctor &
child care facility should keep a current copy of this form in child's record.
APPENDIX M: SPECIAL CARE PLAN FOR A CHILD WITH ASTHMA
Special Care Plan for a Child with Asthma
Medications for routine and emergency treatment of asthma for:
Child's name Date of Birth
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| Name of medication |
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When to use (e.g., symptoms, time of day, frequency, etc.)
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routine or emergency |
routine or emergency |
routine or emergency |
How to use (e.g.,by mouth, by inhaler, with or without spacing device, in nebulizer, with or without dilution, diluting fluid, etc.)
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Amount (dose) of medication
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How soon treatment should start to work
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Expected benefit for the child
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Possible side effects, if any
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Date instructions were last updated by child's doctor
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Date:______ Name of Doctor (print):_______________ Doctor's signature:_______________ |
Parent's permission to follow this medication plan
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Date:______ Parent's signature:_______________ |
If more columns are needed for medication or equipment instruction, copy this page
Reprinted with permission from Child Care and Children with Special Needs Workbook.
Wilmington, DE: Video Active Productions, 2001; 302-477-9440
