Name asthma action plan, for children 6 years or older. If you or your child has asthma that requires daily treatment, it is important to have an asthma action plan. This asthma action plan provides authorization for the administration of medicine described in the aap. These documents are typically aimed toward children who may have trouble managing their conditions. Pediatric asthma action plan personal best peak flow. We distribute aaps to patients in the inpatient and outpatient settings. Asthma action plan, for children 6 years or older, continued doctor doctors phone number. Danger take these medicines and call your doctor now. We want to help your child be free from troublesome symptoms and sleep through the night without coughing or having trouble breathing. It lists the medicines your child needs to take every day to stay well, what to do if their asthma gets worse, and what to do in an asthma attack.
At least two asthma healthcare preventive visits a year. An asthma action plan is a written plan that tells you what asthma medicine to take every day and how to treat an asthma attack. This plan will be shared with school staff who care for my child. Be sure to include the three zones created by the national institutes of healthexternal icon in your plan.
School form policy pdf camp form policy pdf asthma action plan pdf food allergy action plan pdf rescue medication form pdf asthma patient forms. Guidelines from the national asthma education and prevention program the goal of this asthma care quick reference guide is to help clinicians provide quality care to people who have asthma. The asthma action plan chosen should be appropriate for the persons age, treatment regimen, asthma severity, culture, language, literacy level, and ability to selfmanage. If student stays in red zone, begin emergency plan. The advanced tools of the editor will lead you through the editable pdf template. Our library includes some of the many different written asthma action plans available. With a written asthma action plan, its easier for you to measure whether your childs asthma is under control and it lets you know exactly what steps to take when it isnt.
These should be excluded in the students environment as much as possible. If you know what to watch for and what steps to take, you will be able to make timely and appropriate decisions about managing asthma. Asthma action plan check all items that trigger your asthma and things that could make your asthma worse. If there is no improvement, go to the emergency room or call 911. Before taking this form to your health care provider, complete the top left section with. Write down things that make your asthma worse date i got my asthma plan. Everyone with asthma needs his or her own asthma action plan. The goal of asthma selfmanagement is to achieve better health through controlling and preventing asthma attacks. Intermittent mild persistent moderate persistent severe persistent heshe has had many or severe asthma attacksexacerbations school staff.
Work with your health care provider to create a plan that works for you. Assess asthma severity to initiate treatment see page 5. It is important make an asthma action plan that works well for you. Asthma action plan for children age 15 child health bc. I give written authorization for the medications listed. These tools for asthma control were created following the evidencebased guidelines. A written asthma action plan, developed jointly by the health care provider and the patient, will help the patient manage his or her asthma. Asthma action plan library national asthma council australia. An asthma action plan, also known as an asthma management plan, is a detailed plan that an asthma patient should make with the help of his doctor to help him control his condition.
The action plan would include the treatment that the patient is taking for his asthma such as the type of medication he takes and the frequency he observes in taking them, a plan on how he can control his asthma, and. Diagnosis and management 2015, translated action plans available in chinese and punjabi, and fillable pdf. It can help you make quick decisions in case you are not able to think clearly during an attack. Follow the yellow and red zone plans for rescue medicines according to asthma symptoms. Every person with asthma needs to have a personalized asthma action plan. A written asthma action plan encourages selfmanagement of asthma. Allergens animal dander some people are allergic to the flakes of skin or dried saliva from animals with fur or feathers. Asthma action plans asthma initiative of michigan aim. Asthma action plan name school dob health care provider providers phone parentresponsible person parents phone additional emergency contact contact phone asthma severity see reverse side asthma triggers identified things that make your asthma worse.
Create an asthma action plan american lung association. Asthma treatment plan student parent instructions the pacnj asthma treatment plan is designed to help everyone understand the steps necessary for the individual student to achieve the goal of controlled asthma. Shows your childs daily treatment, such as what kind of medicines to take and when to take them. I should continue using my normal medications as directed by my doctor, and remeasure my peak flow every weeks months. Quality asthma care involves not only initial diagnosis and treatment to achieve asthma. Call your asthma provider breathing is hard and fast ribs show when breathing cant sleep or play because of. An asthma action plan is a written document that teaches people how to control ones asthma during emergency situations. Your child should be able to play and be involved in activities like children without asthma. Yellow zone caution continue with green zone medicine and add quickrelief medicine. Asthma action plan take this asthma action plan with you when you visit your doctor if symptoms get worse severe asthma flareupattack needing reliever again within 3 hours, increasing difficulty breathing, waking often at night with asthma symptoms peak flow if used between and.
I need to see my asthma nurse every six months parents get the most from your childs action plan make it easy for you and your family to. Patient forms associated allergists astma specialists. Green zone doing well breathing is good no coughing, wheezing, chest tightness, or shortness of breath during the day or night, and able to do usual activities work, play, and exercise, and peak flow is. This child has the knowledge and skills to selfadminister quickrelief medicine at school or daycare with approval of the school nurse. Cough, wheeze, chest tightness, or shortness of breath, or. Asthma care quick reference national heart, lung, and. The way to complete the online asthma action plan pdf on the internet. A list of the persons triggers and how to avoid them, instructions for taking asthma medicine, information on what to do during an asthma episode, instructions on when to call a doctor, and. Name date next asthma checkup due doctors contact details emergency contact details name phone relationship asthma action plan take this asthma action plan with you when you visit your doctor.
Asthma action plan health library unitedhealthcare. Washington state asthma plan 2016 about the asthma plan this updated version of the washington state asthma plan reflects the current landscape of asthma care and management in washington. The washington asthma initiative and the washington state department of health support the plan. There are many different asthma action plan formats. Using an asthma action plan is especially important if your child has moderate to severe asthma or has had a serious asthma attack in the past. If student improves to yellow zone, send student to doctor or contact doctor. Leickly md professor of clinical pediatrics james whitcomb riley hospital for children. Asthma action plan for children age 618 child health bc. Well no signs of asthma able to do normal activities no problems while sleeping peak flow above. To be completed by parentguardian and student student asthma action card continued student name.
An asthma action plan aap is a written plan that outlines how to manage your childs asthma. A printable version of the children asthma action plan and discharge plan from the asthma model of care keywords. Adapted from finger lakes asthma action plan and nhlbi revised 10. Green use these medicines every day to prevent asthma attacks. Provider instructions for asthma action plan children ages 05 determine the level of asthma severity see table 1 fill in medications fill in medications appropriate to that level see table 1 and include instructions, such as shake well before using use with spacer. Your goal is to prevent and control your asthma attacks.
Asthma action plan pdf fill out and sign printable pdf. An asthma action plan is an important tool to share with caregivers of children with asthma, including daycare providers, schools and aftercare programs. Assess asthma control to determine if therapy should be adjusted see page 6. Date hospitalemergency department phone number green zone doing well no cough, wheeze, chest tightness, or shortness of breath during the day or night can do usual activities and, if a peak flow meter is used, peak flow. And provide you with information on what action to take. Use the schoolaged asthma action plan, asthma action plan for home and school that includes language for schoolaged children to selfcarry their asthma inhaler in school. The asthma action plan will give you information about when and how to use longterm control medications and quickrelief medications. Green zone doing well breathing is good no coughing, wheezing, chest tightness, or shortness of breath during the day or night, and able to do usual activities work, play, and exercise, and peak flow is more than.
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