Asthma Action Plan
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1M
A
A
/ M
P
AINE
STHMA
CTION
ANAGEMENT
LAN
Name:
Date of Birth:
Personal Best / Predicted Peak Flow:
Symptoms:
Action to Take:
G
Z
P
F
= ________ -- _______
REEN
ONE
EAK
LOW
Continue to take your regular controller medicines every day
(see blue box below).
You are doing great if:
Controller medicine is not needed
You aren’t coughing, wheezing or having
difficulty breathing
Use your quick relief medication every 4-6 hours if needed for symptoms of cough, wheeze,
You can sleep through the night without
shortness of breath or dropping peak flows
(see yellow zone)
waking up with cough
You can do your usual activities
Exercise pre-treatment: Take your quick relief inhaler_____________________10-15
Your peak flow is 80-100% of personal
minutes before exercise
( fill in name of inhaler and # of puffs)
best
No exercise pre-treatment needed
Avoid your triggers:
Y
Z
P
F
= _______ -- _______
ELLOW
ONE
EAK
LOW
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
Xopenex MDI _____ puffs
Albuterol MDI _____ puffs
Every 4-6 hours as needed
You are coughing, wheezing, short of
Xopenex neb _____mg
Albuterol neb _____mg
breath, and using quick relief medicine
more than 2 extra times per week
Other: _______________________________________________________________________
You are waking at night due to cough or
wheeze more than 2 times a month
_______________________________________________________________________
You can’t do regular activities
∗If AT SCHOOL, give the quick relief inhaler, then CALL PARENT; may repeat medicine in
Your peak flow is 50-80% of personal
best
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.
if:
R
Z
: G
H
P
F
<________
ED
ONE
ET
ELP NOW
EAK
LOW
Take a nebulizer treatment or 4 puffs of quick relief inhaler medicine now
You are very short of breath
→ If at school, also notify parent
You have a hard time walking or talking
Skin in your neck or between ribs pulls in
Call your healthcare provider now or go to the emergency department OR Call 911
Your quick relief medicine is not helping
Your peak flow < 50% of personal best
Other instructions:
Controller Medications for Persistent Asthma:
Controller Medication
Dose
Frequency
Budesonide Respules
0.25mg
0.5mg
1.0mg
___ times/day
Pulmicort Flexhaler
90mcg
180 mcg
___ puffs ___ times/day
44mcg
50mcg diskus
Use your regular preventive controller
Fluticasone (Flovent)
___ puffs ___ times/day
110mcg
220mcg
medication EVERY DAY as prescribed
Montleukast (Singulair)
4mg
5mg
10mg
At bedtime
by your doctor. This will help your
asthma stay in control by decreasing the
Asmanex 220 mcg
___ puffs ___ times/day
number of asthma flares and by
Symbicort
80/4.5
160/4.5
2 puffs twice daily
improving your overall lung health.
Advair diskus
100/50
250/50
500/50
1 puff twice daily
Other: ____________________________________________________________________
____________________________________________________________________
If patient is a student in school or daycare:
Parent / Guardian Phone Numbers: ________________________________
T
P
/ G
:
____________________________________________________________________
O BE COMPLETED BY
ARENT
UARDIAN
My child may carry and use his / her:
Inhaled Asthma Medicine
Epi-Pen
N/A
Yes
No
Yes
No
I authorize the exchange of medical information about my child’s asthma between the physician’s office and school nurse.
P
/ G
: ____________________________________ D
: ______________
ARENT
UARDIAN SIGNATURE
ATE
T
P
/ H
P
:
O BE COMPLETED BY
HYSICIAN
EALTHCARE
ROVIDER
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)
H
P
: __________________________________ P
#: ___________________ F
#:________________
EALTHCARE
ROVIDER NAME
HONE
AX
H
P
:_______________________________ D
: ____________
EALTH CARE
ROVIDER SIGNATURE
ATE
T
S
N
O BE COMPLETED BY
CHOOL
URSE
: 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
S
N
: ______________________________ S
N
S
_______________________________ D
:_______________
CHOOL
AME
CHOOL
URSE
IGNATURE
ATE
F
#:____________________ P
#:_________________________ E
: _________________________
11/30/07
AX
HONE
MAIL
REVISED
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