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! _____ , ____ 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.

4 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: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.

5 With funds provided by the Cooperative Agreement Number 5U59EH324208-05from the Centers for Disease Control and Prevention (CDC). 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.

6 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!

7 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!

8 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! _____ , ____ 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.

9 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). Its contents are solely theresponsibility of the authors and do not necessarily represent the official views of the to reproduce blank form.

10 Updated May 2011 REQUIRED Healthcare Provider Signature:_____ Date:_____REQUIRED Responsible 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:Less than _____(Less than 50% of Personal Best)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.