Asthma action plan

Name: Date of Birth: Personal Best / Predicted Peak Flow:
Action to Take:
GREEN ZONE PEAK FLOW = ________ -- _______
You are doing great if:
… Continue to take your regular controller medicines every day (see blue box below).
ƒ You aren’t coughing, wheezing or having … Controller medicine is not needed ƒ You can sleep through the night without Use your quick relief medication every 4-6 hours if needed for symptoms of cough, wheeze, shortness of breath or dropping peak flows (see yellow zone) … Exercise pre-treatment: Take your quick relief inhaler_____________________10-15
80-100% of personal
( fill in name of inhaler and # of puffs) Avoid your triggers:
YELLOW ZONE PEAK FLOW = _______ -- _______
Keep taking your controller medicines.
START QUICK RELIEF MEDICATION: ( appropriate box (es); specify dose)
Your asthma is getting worse if:
Make sure that your inhaler is primed first … use a spacer/ chamber more than 2 extra times per week
… Other: _______________________________________________________________________ ƒ You are waking at night due to cough or wheeze more than 2 times a month
_______________________________________________________________________ ƒ Your peak flow is 50-80% of personal
∗If AT SCHOOL, give the quick relief inhaler, then CALL PARENT; may repeat medicine in 10 minutes if not back into green zone. ∗If quick relief medicine is not working or you are not getting better in 24-48 hours, call your healthcare provider. RED ZONE : GET HELP NOW if: PEAK FLOW <________
4 puffs of quick relief inhaler medicine now
ƒ You have a hard time walking or talking ƒ Skin in your neck or between ribs pulls in ƒ Your quick relief medicine is not helping Call your healthcare provider now or go to the emergency department OR Call 911
ƒ Your peak flow < 50% of personal best
Controller Medications for Persistent Asthma:
Controller Medication
ƒ Use your regular preventive controller medication EVERY DAY as prescribed
by your doctor. This will help your
asthma stay in control by decreasing the … Other: ____________________________________________________________________ ____________________________________________________________________ If patient is a student in school or daycare:
Parent / Guardian Phone Numbers: ________________________________
____________________________________________________________________ Inhaled Asthma Medicine … Yes … No
Epi-Pen … Yes … No … N/A
I authorize the exchange of medical information about my child’s asthma between the physician’s office and school nurse. PARENT / GUARDIAN SIGNATURE: ____________________________________ DATE: ______________ TO BE COMPLETED BY PHYSICIAN / HEALTHCARE PROVIDER: … NO changes from previous plan
This student has the knowledge to carry and use: Inhaled Medication … Yes … No
Epi-Pen … Yes … No
Please contact healthcare provider and parent if student is using quick relief medicine more than 2 times a week (i.e. in excess of pre-exercise treatment) HEALTHCARE PROVIDER NAME : __________________________________ PHONE #: ___________________ FAX #:________________ HEALTH CARE PROVIDER SIGNATURE:_______________________________ DATE: ____________ TO BE COMPLETED BY SCHOOL NURSE: Maine law now permits students to carry and use inhaled medications and epi-pen after demonstrating appropriate use to school nurse. This student demonstrates knowledge / skill to carry and use: Quick Relief Inhaler … Yes … No Epi-Pen… Yes … No
SCHOOL NAME: ______________________________ SCHOOL NURSE SIGNATURE _______________________________ DATE:_______________
FAX #:____________________ PHONE #:_________________________ EMAIL : _________________________
REVISED 11/30/07



Norfolk General Hospital Your Group Plan Booklet Keep in a safe place This booklet is a valuable source of information for you and your family. It provides the information you need about the group benefits available through your employer’s group plan with Sun Life Assurance Company of Canada (Sun Life), a member of the Sun Life Financial group of companies. Please keep it in a safe p

Companion – november 201

Helping vets around the world Figure 1: Volunteers working at the Esther Honey Foundation clinic in April this year report on her time in the South Pacific. Aitutaki; clinical signs range from mild number of donations to worthy causes during 2011, including the registered non-profit organisation based on Rarotonga, the largest of the Cook Islands. the sole provider of vete

Copyright © 2010-2018 Pharmacy Drugs Pdf