|Assessment for: _________________________ Completed by: ___________________________ Date: __________|
(Nurse or Parent)
This tool assists the school nurse in assessing if students are achieving good control of their asthma. Its use is particularly indicated for students receiving intensive case management services at school.
With good asthma management, students should:
- Be free from asthma symptoms or have only minor symptoms:
- no coughing or wheezing
- no difficulty breathing or chest-tightness
- no wakening at night due to asthma symptoms
- Be able to go to school every day, unhampered by asthma.
- Be able to participate fully in regular school and daycare activities, including play, sports, and exercise.
Signs that a student's asthma is not well controlled:
- Have no bothersome side effects from medications.
- Have no emergency room or hospital visits.
- Have no missed class time for asthma-related interventions or missed class time is minimized.
Indicate by checking the appropriate box whether any of the signs or symptoms listed below have been observed or reported by parents or children within the past 2-4 weeks (6 months for history). If any boxes are marked, this suggests difficulty with following the treatment plan or need for a change in treatment or intervention (e.g., different or additional medications, better identification or avoidance of triggers).
- Asthma symptoms more than two days a week or multiple times in one day that require quick-relief medicine (short-acting beta2-agonists, e.g., albuterol).
- Symptoms get worse even with quick-relief meds.
- Waking up at night because of coughing or wheezing.
- Frequent or irregular heartbeat, headache, upset stomach, irritability, feeling shaky or dizzy.
- Missing school or classroom time because of asthma symptoms.
- Having to stop and rest at PE, recess, or during activities at home because of symptoms.
- Exacerbations requiring oral systemic corticosteroids more than once a year.
- Symptoms require unscheduled visit to doctor, emergency room, or hospitalization.
- 911 call required.
If you checked any of the above, use the following questions to more specifically ascertain areas where intervention may be needed.
|Are appropriate forms completed and on file for permitting medication administration at school?||By School Staff|
|Has a daily long-term-control medication(s)* been prescribed?|
|Is long-term-control medication available to use as ordered?||Home|
|Is the student taking the long-term-control medication(s) as ordered?||Home|
|Has a quick-relief (short-acting B2-agonist) medication been prescribed?|
|Is quick-relief medication easily accessible?||Home|
|Personal inhaler(s) at school health office|
Is the student using quick-relief medication(s) as ordered…
|o Immediately when symptoms occur?||Home|
|Does the student use correct technique when taking medication?||Home|
|Does the person administering the medication use correct technique?||Home|
|Can the student identify his/her early warning signs and symptoms that indicate the onset of an asthma episode and need for quick-relief medicine?|
|Can the student identify his/her asthma signs and symptoms that indicate the need for help or medical attention?|
|Can the student correctly use a peak flow meter or asthma diary for tracking symptoms?|
|Are the student's asthma signs and symptoms monitored using a Peak Flow, verbal report, or diary?
|o For response to quick-relief medication?||Home|
|o During physical activity?||Home|
|Have triggers been identified?|
|Can student name his/her triggers?|
|Can parents/caregivers list their child's asthma triggers?|
|Are teachers, including physical educators, aware of this student's asthma triggers?|
|Are triggers removed or adequately managed?||Home|
School nurses provide appropriate asthma education and health behavior intervention to students, parents, and school personnel when signs and symptoms of uncontrolled asthma and other areas of concern are identified. If there is an indication for a change in asthma medications or treatment regimen, refer the student and family to their primary care provider or asthma care specialist or help families to find such services as soon as possible.
* Long-term-control medications (controllers) include inhaled corticosteroids (ICS), leukotriene receptor antagonists (LTRA), or combination medicine (long-acting B2-agonists and ICS), cromolyn, or theophylline.