Asthma action plan - from Pediatric Nursing Journal

Appendix: Asthma Action Plan

SCHOOL ASTHMA ACTION PLAN

CINCINNATI HEALTH DEPARTMENT

SCHOOL AND ADOLESCENT HEALTH PROGRAM

Provider: Please complete the following asthma action plan and fax to: ___________________________________________

Student: _________________________________________________ DOB: _________________________________________

School:   _________________________________________________School Phone __________________________________

CLASSIFICATION	TRIGGERS	PEAK FLOW METER	EXERCISE
Well Controlled  Partially Controlled  Uncontrolled ------------------------------------  Intermittent  Mild Persistent  Moderate Persistent  Severe Persistent	Exercise      Colds  Weather      Dust  Animals       Food  Smoke         Air Pollution  Other	Peak Flow Meter Used?          Yes     No PERSONAL BEST =	Pre-exercise medication needed?  Yes  No Medication: How Much: When: Exercise Modifications if any:

GREEN ZONE: Doing Well                       Take control medications every day if prescribed
Symptoms § Breathing is good § No cough or wheeze § Can play and work § Sleeps all night Peak Flow Meter = (More than 80% of personal best)	Control Medications
	Medicine (circle)                                           Dose (Circle)                         How Much/When                to take
	Advair MDI fluticasone/salmeterol) mcg/spray 45/21 115/21 230/21 Puff(s) Times/day Advair Diskus  (fluticasone/salmeterol)mcg/spray 100/50 250/50 500/50 Puff(s) Times/Day Azmacort (triamcinolone)75 mcg/spray MDI Puff(s) Times/Day Flovent  (fluticasone ) Diskus 50 mcg HFA  44 mcg Puff(s) Times/Day Pulmicort  (budesonide )                 0.25 mg 0.5 mg Puff(s) Times/Day Pulmicort Turbuhaler  (budesonide) 200 mcg 400 mcg Puff(s) Times/Day QVAR  (beclomethasone )   40 mcg 80mcg Puff(s) Times/Day Singulair (monteluklast) tablets 4 mg 5 mg 10 mg QAM QPM Symbicort (budesonide/formoterol ) 80 mcg 160 mcg Puff(s) Times/Day Other:
YELLOW ZONE: Getting Worse         Continue control medications if prescribed and ADD relief medication
Symptoms § Some problems breathing § Cough, wheeze or chest tight § Problems working or playing § Wake up at night due to asthma Peak Flow Meter = § (50% - 80% of personal best)		RELIEF MEDICATION
		Albuterol/Xopenex Inhaler  __________  puffs every __________ hours Xopenex                                1 vial every __________hours
		IF symptoms (and peak flow if used) return to GREEN zone after 1 hour THEN: § Take relief medicine every _____ hours for 1-2 days § Change your control medicine by:	IF symptoms (and peak flow if used) DO NOT return to GREEN zone after 1 hour THEN: § Take relief medication again § Change your control medicine by
		§ Contact physician for follow up care	§ Contact physician within _____hours to modify your medication routine
RED ZONE:  Medical Alert!              Continue control medications if prescribed and INCREASE relief medication
Symptoms § Breathing difficult,  hard or fast § Trouble walking or cannot talk § Getting worse not better § Lips or fingernails blue § Nose opens wide § Ribs show § Medicine is not helping Peak Flow Meter = § (0-50% of personal best)		RELIEF MEDICATION
		Albuterol/Xopenex Inhaler ____ puffs every 20 minutes for a total of _______puffs Xopenex                                        1 vial every 20 minutes for a total of 3 vials      Parent must pick student up from school and take to physician for same day medical evaluation
		Go to the hospital or call 911 if : § Still in the RED zone after 15 minutes § If symptoms are severe and not improved immediately with Albuterol § Lips or fingernails are blue or if having trouble walking or talking § If you cannot reach your doctor for help

MD/NP SIGNATURE ______________________________________________________________DATE_______________

MD/NP NAME___________________________________ADDRESS_____________________________________PHONE_________