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Asthma action plan
MAINE ASTHMA ACTION / MANAGEMENT PLAN
Name: Date of Birth: Personal Best / Predicted Peak Flow:
Symptoms:
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)
.
You aren’t coughing, wheezing or having
Controller medicine is not needed
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: _______________________________________________________________________
You are waking at night due to cough or
wheeze more than
2 times a month
_______________________________________________________________________
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
You have a hard time walking or talking
Skin in your neck or between ribs pulls in Your quick relief medicine is not helping
Call your healthcare provider
now or go to the emergency department
OR Call 911
Your peak flow <
50% of personal best
Controller Medications for Persistent Asthma:
Controller Medication
Frequency
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
Source: http://www.brunswick.k12.me.us/wp-content/uploads/2011/07/Maine-AsthmaAction-Management_plan.pdf
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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