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!
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Written by familydoctor.org editorial staff.
American Academy of Family Physicians
Reviewed/Updated: 09/06
Created: 09/00
Copyright © 2000-2008 American Academy of Family Physicians
|This article provides a general overview on this topic and may not apply to everyone. To find out if this article applies to you and to get more information on this subject, talk to your family doctor.
For private, noncommercial use only.
Home | Privacy Policy | Contact Us | About This Site | What's New |
|This article provides a general overview on this topic and may not apply to everyone. To find out if this article applies to you and to get more information on this subject, talk to your family doctor.
For private, noncommercial use only.
Home | Privacy Policy | Contact Us | About This Site | What's New |