HARRISON COUNTY SCHOOLS OFFICE OF HEALTH SERVICES 445 W. Main Street Clarksburg, WV (304) FAX (304)

Transcription

1 HARRISON COUNTY SCHOOLS OFFICE OF HEALTH SERVICES 44 W. Main Street Clarksburg, WV 6 (4) FAX (4) Dear Parent, Date Please complete the enclosed forms and return them to your school nurse. This will serve as a guide for school personnel in direct contact with your child while in the school setting. If your child has emergency medication such as rescue inhaler, epipen or rescue seizure medication, these medications and forms must be delivered to school on or before the first day of school. It is very important everything is complete. Failure to comply with above requirements may result in your child not being able to begin the school year. If you have any additional questions or concerns feel free to contact me at You may also refer to Harrison County Policy Guide or the county website Sincerely, Certified School Nurse *If your child no longer requires a Health Care Plan for the following health condition, please sign below and return to school nurse. My child does not require medication or a care plan for (medical condition). If there is any change in my student's medical condition or they will need to have medication at school, I will notify the school nurse immediately. Parent Signature Date *Please note if your student had an emergency medication (Epi Pen, Diastat, etc.) last school year that they no longer require, the school nurse will need an order from the medical provider stating the medication is no longer needed during the school day.

2 Childhood Asthma Control Test for children 4 to years old. Know the score. This test will provide a score that may help your doctor determine if your child s asthma treatment plan is working or if it might be time for a change. How to take the Childhood Asthma Control Test Step Let your child respond to the first four questions ( to 4). If your child needs help reading or understanding the question, you may help, but let your child select the response. Complete the remaining three questions ( to 7) on your own and without letting your child s response influence your answers. There are no right or wrong answers. Step Write the number of each answer in the score box provided. If your child s score is 9 or less, it may be a sign that your child s asthma is not controlled as well as or less it could be. No matter what the score, bring this test to your doctor to talk about your child s results. Step Add up each score box for the total. 9 Step 4 Take the test to the doctor to talk about your child s total score. Have your child complete these questions.. How is your asthma today? SCORE Very bad Bad Good Very good. How much of a problem is your asthma when you run, exercise or play sports? It's a big problem, I can't do what I want to do. It's a problem and I don't like it. It's a little problem but it's okay. It's not a problem.. Do you cough because of your asthma? Yes, all of the time. Yes, most of the time. Yes, some of the time. No, none of the time. 4. Do you wake up during the night because of your asthma? Yes, all of the time. Yes, most of the time. Yes, some of the time. No, none of the time. Please complete the following questions on your own.. During the last 4 weeks, on average, how many days per month did your child have any daytime asthma symptoms? 4 Not at all - days/mo 4- days/mo -8 days/mo 9-4 days/mo Everyday 6. During the last 4 weeks, on average, how many days per month did your child wheeze during the day because of asthma? 4 Not at all - days/mo 4- days/mo -8 days/mo 9-4 days/mo Everyday 7. During the last 4 weeks, on average, how many days per month did your child wake up during the night because of asthma? 4 Not at all - days/mo 4- days/mo -8 days/mo 9-4 days/mo Everyday Please turn this page over to see what your child s total score means. TOTAL

3 Asthma Control Test TM for teens years and older. Know the score. If your teen is years or older have him take the test now and discuss the results with your doctor Step Write the number of each answer in the score box provided. Step Add up each score box for the total. Step Take the test to the doctor to talk about your child s total score.. In the past 4 weeks, how much of the time did your asthma keep you from getting as much done at work, school or at home? All of the time Most of the time Some of the time A little of the time 4 None of the time. During the past 4 weeks, how often have you had shortness of breath? More than once a day Once a day to 6 times a week Once or twice a week 4 Not at all. During the past 4 weeks, how often did your asthma symptoms (wheezing, coughing, shortness of breath, chest tightness, or pain) wake you up at night or earlier than usual in the morning? 4 or more nights a week or nights a week Once a week Once or twice 4 Not at all 4. During the past 4 weeks, how often have you used your rescue inhaler or nebulizer medication (such as albuterol)? or more times per day or times per day or times per week Once a week or less 4 Not at all. How would you rate your asthma control during the past 4 weeks? Not controlled at all Poorly controlled Somewhat controlled Well controlled 4 Completely controlled The American Lung Association supports the Asthma Control Test and wants everyone years of age and older with asthma to take it. Total Copyright, by QualityMetric Incorporated. Asthma Control Test is a trademark of QualityMetric Incorporated. What does it mean if my child scores 9 or less? If your child s score is 9 or less, it may be a sign that your child s asthma is not under control. Make an appointment to discuss your child s asthma score with their doctor. Ask if you should change your child s asthma treatment plan. Ask your child s doctor about daily long-term medications that can help control airway inflammation and constriction, the two main causes of asthma symptoms. Many children may need to treat both of these on a daily basis for the best asthma control. The GlaxoSmithKline Group of Companies All Rights Reserved.

4 Asthma Assessment Form **Please complete the following form regarding your student s asthma** Student Name Date of Birth School Grade Teacher Parent/Guardian Name Home phone Cell Phone Work Phone. Has your student ever been given a diagnosis of asthma by a physician? Yes/No *If you circled Yes, at what age?. How many days of school did your student miss last year due to asthma? days - days - days 6-9 days -4 days or more days. During the past year, has your student s asthma ever stopped them from taking part in sports, recess, physical education or other school activities? Rarely Only when colds/illness Daily Weekly Monthly 4. In the past month, during the day, how often has your student had a hard time with coughing, wheezing, or breathing? times a week or less More than times a week All the time- throughout the day. Circle which time of year your student has the most difficulty breathing? Fall Winter Spring Summer Year Around 6. Circle which time of day your child has the most difficulty breathing? Morning Afternoon Evening During the Night 7. Circle how often your student uses their rescue inhaler? Rarely Before exercise Only with colds Other 8. Circle how often you refill your student s rescue inhaler? Weekly Monthly Every 6 months Yearly 9. What are your student s early warning signs of an asthma episode? (Circle all that apply) Cough Wheezing Cold symptoms Decreased tolerance to exercise Other (list). In the past month, during the night, how often does your student wake up or have a hard time with coughing, wheezing, or breathing? (Check one) nights a month or less More than nights a month More than nights a week More than 4 nights a week

5 . Does your student recognize the symptoms of an asthma episode and know what to do about it? Yes No (please circle). How many times in the last year has your student: Received oral steroids (Prednisone, Orapred, Medrol, Prelone) for trouble breathing, coughing, chest tightness, or wheezing? Gone to the doctor for an urgent visit for asthma? Gone to the emergency room for asthma? Stayed overnight in the hospital for asthma?. Name of practitioner treating your student s asthma? Office location Phone I rate my student s need for additional knowledge about asthma as: -None -Very Low -Low -Moderate 4-High -Very High (please circle) I rate my student s need to improve skills for self-management of asthma (use of inhalers, peak flow meter, symptom reporting) as: -None -Very Low -Low -Moderate 4-High -Very High (please circle) I rate my student s health problems related to asthma currently as: -None -Very Low -Low -Moderate 4-High -Very High (please circle) I rate my level of concern about asthma posing a safety risk for my student at school as: -None -Very Low -Low -Moderate 4-High -Very High (please circle) Thank you for completing this assessment - Please return to School Nurse Parent/Guardian Signature: Date: *If your student needs emergency medications for their asthma during the school day, you will be required to complete and send in the following: *Forms Needed: Completed Asthma Health Plan Completed Administration of Medication Form ( for each medicine) *The health care practitioner and parent/guardian are required to sign/date each medication form. Physician name stamps are not accepted. *Once these are completed, please return them with inhaler to the school nurse. Please note new forms are required at the beginning of every school year by law. School Nurse Received: Date: *Please contact your school nurse for any questions at *

6 HARRISON COUNTY SCHOOL HEALTH SERVICES EMERGENCY ACTION PLAN ASTHMA Student Name: DOB: Grade/Teacher: EMERGENCY CONTACT INFORMATION Parents/Guardians: Phone #: Phone #: Phone #: Return To School Nurse Alternate Contact: Phone # Phone #: Phone #: *If the School Nurse is in the building please notify nurse immediately!* IF YOU SEE THIS: Onset of Symptoms: Coughing, Wheezing, Shortness of Breath, Chest Tightness, Rapid Breathing, Working Hard to Breath, Anxiety Inhaler to be used minutes prior to gym/recess. Yes No DO THIS: *NEVER send student anywhere alone! * Encourage student to stay calm- breathe in through nose and blow out through mouth. *Student has available Inhaler (Medication) at school and should report to. (Location) *If student has had an asthma attack at school, restrict physical activity and allow the student to rest. *If no relief within minutes, call school nurse and/or parent. For Worsening Symptoms: *Failure of medications to reduce worsening symptoms *Difficulty breathing, walking, & talking *Blue/gray discoloration of lips/fingernails and skin * Call Code Blue *Stay with student and monitor breathing pattern *Call parent/guardian *Call 9 if symptoms continue to worsen (blue lips/fingernails/skin). *Be prepared to start CPR if breathing stops I understand and agree that information in this Emergency Action Plan will be shared with appropriate school staff. Parent/Guardian Signature School Nurse Received and Reviewed: School Nurse Signature Date Date To Be Completed By School Nurse Location of medicine Authorized person to give medicine Feb 6-Green

7 School Harrison County Schools Medication Form Student Information Student Name Last First Middle Birth Date Homeroom Teacher Grade Medication Allergies This section of the Medication Form is to be filled out by a licensed prescriber. Medication orders are valid for the current school year including any summer school programs or extended school year programs. A medication order is required for any prescription and non-prescription (over the counter) medication. If there is any change in medication, dosage, time, or route, a new medication order must be received before the medication can be administered by school personnel. By signing this form, the licensed prescriber is authorizing that this medication may be given at school. (Use one form for each medication) Medication Diagnosis Physician Dose Time Route Intended Effect of Medication Potential Side Effects for this Medication Other Medication(s) taken by student If rectal Diastat/Diazepam or Klonopin is prescribed, may this be administered by unlicensed trained personnel? Yes No *Please note that Nasal Versed cannot be delegated to unlicensed personnel* May the student self-administer their emergency medication per county policy? Yes No May the student carry their emergency medications on them per county policy? Yes No Name and Title of Licensed Prescriber (PRINT) Address Phone Fax Signature of License Prescriber Date Parent/Guardian Parent/Guardian Authorization I understand the following: *Medication must be brought by an adult to the school in the original container and properly labeled with the child s name. *The licensed prescriber may be contacted concerning the medication order for reasons including, but not limited to clarification, effectiveness, administration time, dosage, discontinuation, or new medication order. *Medication administration and procedures may be delegated to school personnel who have been trained by and remain under direct or indirect supervision of the school nurse. *A photograph of my child may be taken to assist in the correct administration of my child s medication. *Information may be shared with appropriate school personnel to insure the safety of my student. *it is the parent/guardian responsibility to replenish long-term and emergency medications as needed and retrieve unused or expired medication from the school. *At no time will non-emergency medication be sent home with the student. It will be the responsibility of a parent/guardian to pick up all remaining medications from the school. I hereby give permission for my child to receive medication at school per the Harrison County Schools Medication Policy and as ordered by my child s licensed prescriber. I have read and understand that Harrison County Board of Education and its employees are exempt from any liability, except for willful and wanton conduct. Parent/Guardian Signature Date Form Received and Reviewed by School Nurse Date Signature