ASTHMA ACTION PLAN



|CHILD AND ADULT |ASTHMA ACTION PLAN _ |PAGE ONE |

This plan will help you control your asthma, provide you with a summary of your medications, and help you remember what to do during an asthma episode. Please keep a copy with you at all times. Our goal is for you to:

|Be active without having asthma symptoms, including exercise or sports. |Hospital Name |

|Sleep through the night without having asthma symptoms |ADDRESS |

|Prevent asthma episodes or attacks |City State Zip |

|Have the best possible peak flow |Phone number Hospital |

|Avoid side effects from medications |RESCUE: 911 |

This plan is based on PEAK FLOW monitoring. You should do this twice a week if your asthma is well controlled but twice a day (a.m. & p.m.) if not or when you are symptomatic. Measure your peak flow before and after any inhaled medications. Always take the best of 3 consistent readings. If you have not taken at least 2 weeks to measure your peak flow at least 2x/day to determine your personal best peak flow, talk with Dr. Wallace.

|Established Dx. |Drug Allergies:       |Ht.       |

|      | |Wt.       |

|      |      |Home Meter       |

|      |      |Best Home      |

|      |      |Best Office      |

|      |      |      |

Major Inhalant Allergen:      

Food Allergens to avoid:      

Common Triggers for many asthmatics: Viral infections, exercise, laugh/cough, smoke, perfume, pollution, cold air or weather changes, stress, and allergen exposure.

Follow your GREEN ZONE plan every day to keep most asthma symptoms from starting. Recognize your symptoms of an asthma episode and act quickly to stop them.

Follow your YELLOW ZONE plan to stop asthma symptoms and keep an asthma episode from getting serious.

Follow your RED ZONE plan to take care of a serious episode. THIS IS AN EMERGENCY PLAN!

GREEN ZONE: 80-100% of Personal Best:      . Check Peak flow 2x/week.

|DAILY PLAN TO KEEP ASTHMA SYMPTOMS UNDER CONTROL |GREEN ZONE: |

|TAKE MEDICATIONS EVEN IF YOU HAVE NO SYMPTOMS | |

|1       (CONTROLLER) |NO SIGNS OR SYMTPOMS OF ASTHMA |

|2       (CONTROLLER) |Breathing is good |

|3       (CONTROLLER) |No early warning signs or asthma |

|4       |Normal Activity and sleep |

|5       | |

|6       (QUICK RELIEF) | |

| EXERCISE ASTHMA: If you usually experience asthma symptoms with exercise, use your QUICK RELIEF MEDICATION 15| |

|minutes before exercise. | |

|CHILD AND ADULT |ASTHMA ACTION PLAN |PAGE 2 |

YELLOW ZONE: 60-80% of Personal Best      

|1. USE YOUR QUICK RELIEF MEDICATION       IMMEDIATELY |YELLOW ZONE: CAUTION! |

| Wait 20 minutes. Repeat Peak Flow |WORSENING ASTHMA |

| A If Peak Flow is greater than       (80%) and symptoms have resolved, |Cough, wheeze, shortness of breath, chest tightness, |

| |chest heaviness |

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| Return to your GREEN ZONE PLAN |↑ Tiredness |

| NOTE: If you enter your YELLOW ZONE 3 or more times/week, call to |↑ Allergy symptoms |

| set up an office visit with Dr. FILL INwithout one week. |↓ Quality of sleep |

| B If Peak Flow is less than       (80%) OR symptoms continue, |↓ Usual activity level |

| Repeat QUICK RELIEF MEDICATION (see above), wait 20 minutes, & If Peak Flow is now greater than |

|       (80%) and symptoms have improved: |

|Use Quick Relief Medication every 6 hours for 24 hours | |

|Continue with Green Zone Medications. | |

| C If after QUICK RELIEF MEDICATION has been used two times and your peak flow is less than       (80%) but greater than       (60%) AND you have reduced |

|asthma symptoms follow the below plan. Otherwise go to RED ZONE plan: |

| 1) Use Quick Relief Medication every 6 hours for 24 hours | |

| 2) Take all Green Zone Medication but make these Changes: | |

| a)       |

| b)       | |

| 3) Add       |

| 4)       |

| 5) Call Dr. Wallace for an office visit within 3 days |

| |

|2. MEASURE PEAK FLOW 2 TIMES/DAY FOR ONE WEEK |

| |

RED ZONE: PEAK FLOW is under 60% of Personal Best      

| | |

|This is an EMERGENCY!! GET HELP!!! |RED ZONE: MEDICAL ALERT |

| | |

|1. USE YOUR QUICK RELIEF MEDICATION       IMMEDIATELY |Trouble talking, walking, or thinking |

| Repeat every 20 minutes until you have taken three treatments |Shoulders go up |

| 2. Call Dr. FILL IN or Primary Care Dr. or 911 NOW! |Neck & ribs move in when breathing |

| 3. Take Oral Steroids:       |Grey or blue skin color, staring around mouth |

| 4. You must get medical attention today even if your symptoms start to improve |Severe and constant coughing, wheeze, shortness of|

| |breath |

| |Inability to sleep |

| | |

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