Asthma Action Plan
for ___________________________
Date _________
Doctor's Name __________________
Doctor's Phone Number _________________
Hospital/ Emergency Room Phone Number __________________
Asthma Action Plan
Asthma Action Plan
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: more than _____________ (80% or more of my best peak flow)
My best peak flow is: _____________
Peak flow: more than _____________ (80% or more of my best peak flow)
My best peak flow is: _____________
| Medicine | How Much to Take | When to Take it |
|---|---|---|
Take these long-term control medicines each day (include an anti-inflammatory)
YELLOW ZONE: Asthma Is Getting Worse
- Cough, wheeze, chest tightness or shortness of breath, or
- Waking at night due to asthma, or
- Can do some but not all usual activities
--Or--
Peak Flow: __________ to _________ (50% to 80% of my best peak flow)
First, add the following quick-relief medicine -- and keep taking your GREEN ZONE medicine:
_________________________
(short-acting beta-agonist)
Please circle one of the following:
Peak Flow: __________ to _________ (50% to 80% of my best peak flow)
First, add the following quick-relief medicine -- and keep taking your GREEN ZONE medicine:
_________________________
(short-acting beta-agonist)
Please circle one of the following:
- 2 puffs every 20 minutes for up to one hour,
- 4 puffs every 20 minutes for up to one hour, or
- nebulizer once
Second, if your symptoms (and peak flow, if used) return to GREEN ZONE after 1 hour of above treatment:
Please circle one or both of the following:
Please circle one or both of the following:
- Take the quick-relief medicine every 4 hours for 1 to 2 days
- Double the dose of your inhaled steroid for _______________ (7-10) days
-Or-
If your symptoms (and peak flow, if used) do not return to Green Zone after 1 hour of above treatment:
Please circle one, two or all of the following:
If your symptoms (and peak flow, if used) do not return to Green Zone after 1 hour of above treatment:
Please circle one, two or all of the following:
- Take: (short-acting beta-agonist) __________________ 2 or 4 puffs or nebulizer.
- Add: (oral steroid) _________________________________ mg per day. For ___________ (3-10) days.
- Call the doctor before/within __________________ hours after taking the oral steroid.
RED ZONE: Medical Alert!
- Very short of breath, or
- Quick-relief medicines have not helped, or
- Cannot do usual activities, or
- Symptoms are same or get worse after 24 hours in Yellow Zone
-Or-
Peak flow: less than ___________________ (50% of my best peak flow)
Peak flow: less than ___________________ (50% of my best peak flow)
Take This Medicine:
___________________________________
(short-acting beta-agonist)
Please circle one of the following:
___________________________________
(short-acting beta-agonist)
Please circle one of the following:
- 4 puffs,
- 6 puffs, or
- nebulizer
-And/Or-
_______________________ ________mg
(oral steroid)
Then call your family doctor NOW.
Go to the hospital or call for an ambulance if:
You are still in the red zone after 15 minutes AND You have not reached your doctor.
_______________________ ________mg
(oral steroid)
Then call your family doctor NOW.
Go to the hospital or call for an ambulance if:
You are still in the red zone after 15 minutes AND You have not reached your doctor.
DANGER SIGNS
- Trouble walking and talking due to shortness of breath
- Lips or fingernails are blue
Take 4 or 6 puffs (please circle) of your quick-relief medicine AND go to the hospital or call an ambulance (phone number ______________ ) NOW!
PDF Version
More Information
Source
Written by familydoctor.org editorial staff.
American Academy of Family Physicians
Reviewed/Updated: 12/09
Created: 09/00