Work with your health care provider to create a plan for your child. School health forms and action plans schoolage health. 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. 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. Asthma action plans for indigenous australians remote indigenous australian short wind asthma action plan. It allows one to begin treatment early to prevent a fullblown asthma episode. 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 peak expiratory flow is 80% or more than your personal best2,3,4. Asthma symptom control means how often in the last four weeks you had asthma symptoms, used your reliever. Adult and child asthma action plans this form, when completed by health care providers, gives parents and school personnel a written asthma management plan for children. Put a check next to the triggers that you know make your asthma worse and ask your doctor to help you find out if you have other triggers as well. Many people with asthma are allergic to dust mites.
Then decide with your doctor what steps you will take. More importantly, it can stop your child ending up in hospital with an asthma attack. 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. Due to a medical diagnosis of asthma, the medication listed below needs to be given during the regular school day according to the following protocol. Im a plastic tube that your puffer fits into to help the medicine get to your lungs.
No interference with usual physical activities or exercise1. Select the one that is best for you, print a copy and fill in the information requested. Connecticut department of health asthma action plans in pdf and. Texas catholic conference education department, 2014 126 sample asthma action plan, p. It is my pleasure to support the asthma initiative of michigans third strategic plan, asthma in michigan 2014. Give copies of the asthma treatment plan to everyone who provides care for your child, for example.
An asthma action plan is an interventional tool that helps patients to control their condition. This plan has information and instructions on how to manage your asthma. Every person with asthma needs to have a personalized asthma action plan. How to use medicines asthma triggers to avoid how to respond to worsening symptoms when to call the doctor when to seek emergency care sample asthma action plans. It has sections for information about medicines, how to know when your symptoms get worse and what to do in an emergency.
If so, what steps have you taken to work toward your goals. The effectiveness of written asthma action plan at the. I consent to communication between the prescribing health care providerclinic, the school nurse, the school medical advisor. Virginia asthma coalition asthma action plan pdf virginia diabetes council medical management plan and protocol supplement. Many people with asthma are allergic to the dried droppings and remains of cockroaches. See the reverse side for things you can do to avoid your asthma triggers. Asthma action plan national heart, lung, and blood institute. Asthma action plan, for children 6 years or older, continued doctor doctors phone number. These should be excluded in the students environment as much as possible. A written asthma action plan encourages selfmanagement of asthma.
Asthma action plans also tell school and other caregivers about your childs asthma. Asthma action plans an asthma action plan is a tool to help selfmanage asthma and is developed with the patient, caregiver and doctor. Symptoms are same or worse after 24 hours in the yellow zone or very short of breath or. Our library includes some of the many different written asthma action plans available. Although asthma has no cure, successful selfmanagement practices exist to improve both frequency and severity of symptoms andrews et al. When you have good control over your asthma you should have no symptoms. In addition to summarizing the burden of asthma, the plan provides goals, objectives, action steps and measures for success.
Aim partners will be informed of current asthma data and identified best. Minnesota department of health s interactive asthma action plan is a computerbased program that uses information entered by the healthcare provider to create a personalized plan for each patient. The plan lists daily and rescue medications with steps to take when asthma symptoms occur. I assume full responsibility for providing the school with prescribed medication and delivery monitoring devices. This presentation details the burden of asthma in massachusetts and the 2009 2014 strategic plan goals to improve asthma control for massachusetts residents. Presidents task force on environmental health risks and. Use poison baits, powders, gels, or paste for example, boric acid. My written asthma action plan helps me judge how well i am and know what i need to do if im not. Before taking this form to your health care provider, complete the top left section with. Reliever medication is safe to administer to children, even if they do not have asthma, however if there is no asthma action plan you must also call emergency assistance to attend 000 and notify the parentcarer of the child as soon as possible. Using quick relief medicine more than 2 times a week not counting use before exercise. Assess asthma severity to initiate treatment see page 5.
Global initiative for asthma global initiative for. This guide suggests things you can do to avoid your asthma triggers. 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. Symptoms are same or worse after 24 hours in the yellow zone or very short of breath or quickrelief asthma medicines have not helped or cannot do usual activities work, play peak flow meter if used. Asthma action plan library national asthma council australia. I consent to communication between the prescribing health care provider or clinic, the school nurse, the school medical advisor and school. This brochure provides an asthma action plan that will help you learn the steps to selfmanage your asthma so you can live a life as symptomfree as possible. Take a photograph of it and keep it on your phone you can check what to do if your asthma gets worse. For more information contact the asthma society of canada at. Take my quickrelief asthma medicine as directed by my doctor action plan. Four key components of asthma selfmanagement outlined by the most recent 2007 expert panel report asthma guidelines include usage of an asthma action plan aap, consistent observance of asthma. This could include teachers, school nurses, and after school care staff. The asthma action plan chosen should be appropriate for the persons age, treatment regimen, asthma severity, culture, language, literacy level, and ability to selfmanage.
This is the asthma action plan for dc public schools provided by the department of health. Adapted from finger lakes asthma action plan and nhlbi revised 10. Make changes and reselect the correct letter template. My asthma action plan times per day every day take only noas needed see below starting in yellow zone or before excercise times per day every day times per day every day 2 puffs 46 puffs 1 nebulizer treatment gargle or rinse mouth after use special instructions when i am doing well be careful ask for help asthma triggers check all that. The above named person is a patient currently under my medical care. Here is a sample asthma action plan you can use for students in school. I give written authorization for the medications listed in the action plan to be administered in school by the nurse or other school members as appropriate. To be completed by parentguardian and student student asthma action card continued student name.
The focus of the plan is to reduce asthma burden by concentrating on communities and populations enduring asthma disparities. I give permission for the medicines listed in the action plan to be administered in school by the nurse or other school staff as appropriate. The action plan presents a framework to maximize the use of our existing federal resources for addressing this major public health challenge during the next three to. Nov 27, 2019 furthermore, asthma clinics offer different approaches to help patients understand their roles in the management of their condition, one example of an approach done by the asthma clinic is a written asthma action plan. The main goal of the state plan is to reduce the impact of asthma. Cumberland county schools asthma medication plan rev. Asthma control means the extent to which the effects of asthma can be seen, or have been reduced or removed by treatment. My asthma action plan childrens healthcare of atlanta. Pubmed comprises more than 26 million citations for biomedical literature from medline, life science journals, and online books. Citations may include links to fulltext content from pubmed central and publisher web sites. An asthma action plan is needed on all asthmatic students. No coughing, shortness of breath, wheezing, or chest tightness sleeping all night can do all usual activities work, play peak flow meter if used.
Management of asthma for sample asthma action plans. Assess asthma control to determine if therapy should be adjusted see page 6. Name asthma action plan, for children 6 years or older. Your childs less likely to have asthma symptoms or an asthma attack. Intermittent mild persistent moderate persistent severe persistent.
Caution, my asthma symptoms are getting worse red zone. What asthma symptoms are you experiencing wheezing, coughing, chest tightness, shortness of breath. This asthma action plan is adapted from the asthma action plan created by the national institutes of health. The global initiative for asthma gina strives to increase awareness of asthma among health professionals, health authorities, and the general public. National prevalence of asthma attacks 2014 characteristic number of persons with current asthma who reported having one or more asthma attacks in thousands percent of persons with current asthma who reported having one or more asthma attacks. Dont put yourself in a position where youre looking back, thinking things could have been different if youd only used an action plan. My asthma action plan name date doctor doctors phone number symptoms my breathing is normal. School health forms and action plans schoolage health and. What is the difference between asthma and viralinduced wheeze viw. Read our tips on getting the best from a childs asthma action plan. I give permission for school personnel to share this information, follow this plan, administer medication and care for my child and, if necessary, contact our physician.
What is the difference between asthma and viralinduced. Asthma action plan mild intermittent mild persistent moderate persistent severe persistent colds exercise animals other 1. The plan directs efforts toward people with asthma, their families, health care providers, educators, employers, policymakers and communities to control asthma in homes, schools, workplaces, childcare settings and the community. Connecticut department of health asthma action plans in pdf.
This asthma action plan was developed specifically for indigenous peoples with asthma who live in remote areas of australia. Bring your written answers to your next appointment and discuss them with. I should continue using my normal medications as directed by my doctor, and remeasure my peak flow every weeks months. 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. Links with this icon indicate that you are leaving the cdc website the centers for disease control and prevention cdc cannot attest to the accuracy of a nonfederal website. Asthma action plan for older children childrens healthcare of atlanta. Need for reliever medication, less than 4 times a week1.
What things triggers make your asthma symptoms worse. Quality asthma care involves not only initial diagnosis and treatment to achieve asthma. It will also assist with medication choices according to symptoms and peak flow numbers. Asthma care quick reference national heart, lung, and. If a spray is used to kill roaches, stay out of the room until the odor. The following plan will provide instructions according to the symptoms found.
Copies of the peak flow based symbicort smart asthma action plan are available from astrazeneca. Asthma action plan what to look out for asthma medicines preventers your. I give permission for the school nurse and any pertinent staff caring for my child to follow this plan, administer medication and care for my child, contact my asthma care provider if necessary and for this form to be faxedemailed to my childs school or be shared with school staff per ferpa guidelines. Floridas state asthma plan the florida asthma plan 2009 2014 is a fiveyear strategic plan that will serve as the detailed blueprint for addressing asthma in florida. Our goals include improving diagnoses, management and prevention of asthma by stimulating research, and providing evidencebased educational resources for worldwide use. Everyone with asthma should have a written asthma action plan. Take a photograph of it and keep it on your phone you can check what to do if your asthma. Child care provider, privateparochial school, head start program, local health departments, day or residential camp, or others.
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