Rev. 06.01.15 Copy: School File NOTE: This plan will be shared with all appropriate school district staff
Huron Valley Schools – Plan of Care (POC)
Allergy/Asthma Management
Bus Route #: ___________
Student Name: _________________________________ School: ______________________ Grade: __________
The student’s asthma and ___________________ allergy can be life threatening. Signs of an allergic reaction and
asthma episode may include the following: (items checked are ones usually experienced by the student)
Signs of an allergic reaction include:
*Mouth: Itching and Swelling of the Lips Tongue
Mouth
*Throat: Itching Sense of Tightness in the Throat
Hacking Cough
Skin: Hives Itchy Rash Swelling about the Face or
Extremities
Gut: Nausea Abdominal Cramps Vomiting
Diarrhea
*Lung: Shortness of Breath Repetitive Coughing
Wheezing
*Heart: Thready Pulse Fainting
Signs of an asthma episode include:
Coughing
Wheezing
*Difficulty Breathing, Walking, Talking
*Blue or Grey Discoloration of Lips or Fingernails
*Increased Anxiety
Other
If the student experiences the above symptoms
1. Calm student
2. Encourage slow, deep breathing exercises
3. Give medication____________________________
(Doctor, please indicate type of medication above)
4. Stay with student fifteen (15) minutes.
5. Send back to class if improved status.
6. Contact Parents.
*The severity of the above symptoms can quickly change. Above symptoms can potentially progress to a
life-threatening status.
If the student suspects that an allergic reaction is happening or if the student experiences any feeling of the
throat closing:
Treat as a MAJOR Reaction:
Inject one Epi-Pen immediately into the student’s upper outer thigh
Call 911
Monitor closely until help arrives
Call Parents: Home Phone: ____________________
Mother: ________________________________Cell Phone: __________________Work Phone:_______________
Father: ________________________________Cell Phone: __________________Work Phone: _______________
In the event that special accommodations are required, the school district may need up to five (5) school days to comply with the
request. It will be up to the parent and the physician to determine if the child shall attend school during that time.
_______________________________ ___________ _________________________________ ____________
PARENT SIGNATURE DATE PHYSICIAN SIGNATURE DATE
Physician Name_________________________________
Physician Address_______________________________
Physician Phone_________________________________
