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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



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Companion – november 201

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