HELPING CHILDREN GAIN ASTHMA CONTROL1

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______