CNMC Asthma Action Plan UPO

1 Asthma Action PlanName SchoolDOBH ealth Care ProviderProvider s PhoneParent/Responsible PersonParent s PhoneAdditional Emergency ContactContact PhoneAsthma Severity(see reverse side) Asthma Triggers Identified (Things that make your Asthma worse): Intermittent orPersistent: Mild Moderate SevereAsthma Control Well-controlled Needs better control Colds Smoke (tobacco, incense) Pollen Dust Animals_____ Strong odors Mold/moisture Pests (rodents, cockroaches) Stress/emotions Gastroesophageal reflux Exercise Season: Fall, Winter, Spring, Summer Other:_____ /___ /___Green Zone: Go!

2 Take these CONTROL (PREVENTION) Medicines EVERY DayYou have ALLof these: Breathing is easy No cough or wheeze Can work and play Can sleep all night No control medicines required. Always rinse mouth after using your daily inhaled medicine. _____ , _____ puff(s) inhaler with spacer_____ times a dayInhaled corticosteroid or inhaled corticosteroid/long-acting agonist _____ , _____ nebulizer treatment(s)_____ times a dayInhaled corticosteroid _____ , take_____ by mouth once daily at bedtimeLeukotriene antagonistFor Asthma with exercise, ADD: _____ , _____ puff(s) inhaler with spacer 15 minutes before exerciseFast-acting inhaled agonistFor nasal/environmental allergy, ADD: _____Yellow Zone: Caution!

3 Continue CONTROL Medicines and ADDQUICK-RELIEFM edicinesYou have ANYof these: First sign of a cold Cough or mild wheeze Tight chest Problems sleeping,working, or playingYou have ANYof these: Can t talk, eat, or walk well Medicine is not helping Breathing hard and fast Blue lips and fingernails Tired or lethargic Ribs show _____ , _____ puff(s) inhaler with spacerevery _____ hours as neededFast-acting inhaled agonistOR _____ , _____ nebulizer treatment(s) every _____ hours as neededFast-acting inhaled agonist Other_____Call your DOCTOR if you have these signs more than two timesa week, orif your quick-relief medicine doesn t work!

4 _____ , ____ puff(s) inhaler with spacer every 15 minutes,for 3treatmentsFast-acting inhaled agonistOR _____ , ____ nebulizer treatment every 15 minutes,for 3treatmentsFast-acting inhaled agonistCall your doctor while giving the treatments. Other_____IF YOU CANNOT CONTACT YOUR DOCTOR: Call 911 for an ambulanceor go directly to the Emergency Department!Red Zone: EMERGENCY! Continue CONTROL & QUICK-RELIEF Medicines and GET HELP! of theDistrict of ColumbiaVincent C. Gray, MayorDate ofLast FluShot:SCHOOL MEDICATION CONSENT AND PROVIDER ORDER FOR CHILDREN/YOUTH:Possible side effects of quick-relief medicines ( , albuterol) include tachycardia, tremor, and Provider Initials:____This student is capable and approved to self-administer the medicine(s) named student is notapproved to authorization is valid for one calendar the RESPONSIBLE PERSON.

5 I hereby authorize a trained school employee, if available, to administer medication to hereby authorize the student to possess and self-administer hereby acknowledge that the District and its schools, employees and agents shall be immunefrom civil liability for acts or omissions under Law 17-107 except for criminal acts,intentional wrongdoing, gross negligence, or willful from NAEPP by Children s National Medical CenterCoordinated by the National Capital Asthma CoalitionThis publication was supported in part by a grant from the DC Department of Health AsthmaControl Program, with funds provided by the Cooperative Agreement Number 5U59EH324208-05from the Centers for Disease Control and Prevention (CDC).

6 Its contents are solely theresponsibility of the authors and do not necessarily represent the official views of the to reproduce blank form. Updated May 2011 REQUIREDH ealthcare Provider Signature:_____ Date:_____REQUIREDR esponsible Person Signature:_____ Date:_____Follow up with primary doctor in 1 week or:_____ Phone:_____ Patient/parent has doctor/clinic number at homePeak flow in this area:_____ to_____(More than 80% of Personal Best)Personal best peak flow:_____/ /Peak flow in this area:_____ to_____(50%-80% of Personal Best)Peak flow in this area.

7 Less than _____(Less than 50% of Personal Best)DO NOT WRITE IN THIS SPACEP lace Patient Label HereName SchoolDOBH ealth Care ProviderProvider s PhoneParent/Responsible PersonParent s PhoneAdditional Emergency ContactContact Phone/ /Government of theDistrict of ColumbiaVincent C. Gray, Action PlanAsthma Severity (see reverse side) Asthma Triggers Identified (Things that make your Asthma worse): Intermittent orPersistent: Mild Moderate SevereAsthma Control Well-controlled Needs better control Colds Smoke (tobacco, incense) Pollen Dust Animals_____ Strong odors Mold/moisture Pests (rodents, cockroaches) Stress/emotions Gastroesophageal reflux Exercise Season: Fall, Winter, Spring, Summer Other:_____ /___ /___Green Zone: Go!

8 Take these CONTROL (PREVENTION) Medicines EVERY DayYou have ALLof these: Breathing is easy No cough or wheeze Can work and play Can sleep all night No control medicines required. Always rinse mouth after using your daily inhaled medicine. _____ , _____ puff(s) inhaler with spacer_____ times a dayInhaled corticosteroid or inhaled corticosteroid/long-acting agonist _____ , _____ nebulizer treatment(s)_____ times a dayInhaled corticosteroid _____ , take_____ by mouth once daily at bedtimeLeukotriene antagonistFor Asthma with exercise, ADD: _____ , _____ puff(s) inhaler with spacer 15 minutes before exerciseFast-acting inhaled agonistFor nasal/environmental allergy, ADD: _____Yellow Zone: Caution!

9 Continue CONTROL Medicines and ADDQUICK-RELIEF MedicinesYou have ANYof these: First sign of a cold Cough or mild wheeze Tight chest Problems sleeping,working, or playingYou have ANYof these: Can t talk, eat, or walk well Medicine is not helping Breathing hard and fast Blue lips and fingernails Tired or lethargic Ribs show _____ , _____ puff(s) inhaler with spacerevery _____ hours as neededFast-acting inhaled agonistOR _____ , _____ nebulizer treatment(s) every _____ hours as neededFast-acting inhaled agonist Other_____Call your DOCTOR if you have these signs more than two timesa week, orif your quick-relief medicine doesn t work!

10 _____ , ____ puff(s) inhaler with spacer every 15 minutes,for 3treatmentsFast-acting inhaled agonistOR _____ , ____ nebulizer treatment every 15 minutes,for 3treatmentsFast-acting inhaled agonistCall your doctor while giving the treatments. Other_____IF YOU CANNOT CONTACT YOUR DOCTOR: Call 911 for an ambulanceor go directly to the Emergency Department!Red Zone: EMERGENCY! Continue CONTROL & QUICK-RELIEF Medicines and GET HELP!Date ofLast FluShot:Adapted from NAEPP by Children s National Medical CenterCoordinated by the National Capital Asthma CoalitionThis publication was supported in part by a grant from the DC Department of Health AsthmaControl Program, with funds provided by the Cooperative Agreement Number 5U59EH324208-05from the Centers for Disease Control and Prevention (CDC).