If your child has symptoms with exercise, it may mean that hisher asthma is not well controlled. Asthma action plan for children age 15 child health bc. Child asthma action plan for ages 0 to 5 years of age sutter health. Both the healthcare provider and the parentguardian feel that the child has demonstrated. Many children may need to treat both of these on a daily basis for the best asthma. Make sure that all patients have a written asthma action plan. Danger signs asthma emergency severe breathing problems, symptoms get worse very quickly, reliever has little or no effect. Provider instructions for asthma action plan children ages 05 determine the level of asthma severity see table 1 fill in medications fill in medications appropriate to that level see table 1 and include instructions, such as shake well before using use with spacer. This brochure is an asthma action plan for doctors to complete and give to child patients and their parentscaregivers. Always use a spacer, some children may need a mask. 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 80% of your child s personal best personal best. Asthma action plan take this asthma action plan with you when you visit your doctor. Kids first aid for asthma chart national asthma council australia.
Create an asthma action plan american lung association. Living with asthma seattle children s hospital 5 controlling asthma is the goal learn your unique signs and act early take your medicines make an asthma plan and follow it work with your medical team avoid your triggers you can co ntrol your asthma. If you can, print out a copy to take to your gp or asthma nurse. Here is a sample asthma action plan you can use for a child in preschool, day care, etc download pdf. Massachusetts asthma action plan personal best peak flow. Asthma action plans also tell school staff and other caregivers about your child s asthma. If you have a child in a connecticut licensed day care facility, the asthma action plan does not meet the requirements of day care licensing regulations for an authorization to administer medication. And a booklet packed with tips and ideas about how you can help your child manage their asthma well so they can get on with enjoying life. See your doctor every 3 to 6 months for an asthma checkup. A short course of ocs may be needed during severe asthma flareups exacerbations. Perform skin or blood allergy tests for all patients with persistent asthma. Allergens animal dander some people are allergic to the flakes of skin or dried saliva from animals with fur or feathers. Adapted from naepp by children s national medical center coordinated by the national capital asthma coalition this publication was supported in part by a grant from the dc department of health asthma control program, with funds provided by the cooperative agreement number 5u59eh32420805 from the centers for disease control and prevention cdc.
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. Asthma action plan name date of birth gradeteacher health care provider health care providers office phone medical record number. Work with your health care provider to create a plan for your child. You can give it to teachers, school nurses and afterschool care staff. I approve this care plan and give permission for school personnel to share this information, follow this plan, administer medication. The child should feel better within 2060 minutes of the quickrelief treatment. Assess asthma control to determine if therapy should be adjusted see page 6. These plans are designed to complement the childs asthma management plan, whether it. This asthma action plan provides authorization for the administration of medicine described in the aap. Asthma action plan library national asthma council australia.
Regular play and exercise is good for your child s health. Pediatric asthma action plan the lung health foundation. Childhood asthma control test for children 4 to 11 years old. Take it to your doctor and have them fill it out for you. By following the steps written in the general action plan, you can help your child perform normal, daytoday activities without experiencing alarming episodes or symptoms of asthma. Book an asthma appointment with your gp or asthma nurse. Green go breathing is good no cough or wheeze can work and play peak flow number to. If youre not using an asthma action plan yet, its easy to get started. Asthma action plan yellow zone use a spacer with metered dose inhalers. An asthma action plan has all the information you need in one place so you can look after your childs asthma well. An action plan tells the patient how to recognize worsening asthma, how to increase their reliever and controller medications, and when to seek medical help. If the person has known severe allergies and seems to be having a severe allergic reaction, use. Well no signs of asthma able to do normal activities no problems while sleeping peak flow above.
Asthma action plans national asthma council australia. Before taking this form to your health care provider, complete the top left section with. Our library includes some of the many different written asthma action plans available. Asthma action plan take this asthma action plan with you when you visit your doctor if symptoms get worse severe asthma flareupattack needing reliever again within 3 hours, increasing difficulty breathing, waking often at night with asthma symptoms peak flow if used between and. Here is a sample asthma action plan you can use for students in school. Patientcentered asthma care minnesota department of health. Every asthma education appointment is scheduled for 60 minutes and includes spirometry 6 years or older, selfmanagement skills. Circle the triggers that make your child s asthma worse. Asthma action plan and discharge plan for children wa health. The colors of a traffic light will help you use your asthma medicines.
This action plan on asthma is usually divided into three zones which are named after the colors of a traffic light. Follow the persons action plan for anaphylaxis if available. As well as your child s asthma action plan, our awardwinning my asthma pack contains a calendar and stickers to help you and your child track their asthma symptoms. Provider instructions for asthma action plan children ages 05 determine the level of asthma severity see table 1 fill in medications fill in medications appropriate to that level see table 1 and include instructions, such as shake well before using use with spacer, and rinse mouth after using. Patient name dob asthma action plan, for children 6 years or older, continued doctor doctors phone number. Print a copy and take with you when you see your healthcare provider so you can fill it out together. Asthma action plan childrens healthcare of atlanta. Does your child have any of the following symptoms when they seem well. Assess asthma control at every visit by selfadministered standardized test or verbal history. Asthma action plans also tell school and other caregivers about your child s asthma. Parents should give a copy of their child s asthma action plan to the school, preschool andor childcare facility. 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.
Please use the following authorization to administer medication form. A plan can be very helpful, especially during an asthma flareup. Adapted from finger lakes asthma action plan and nhlbi revised 10. Asthma provider printed name and contact information. A printable version of the children asthma action plan and discharge plan from the asthma model of care keywords. The asthma action plan is a document that details the symptoms a patient should watch out for on his asthma and how to treat them accordingly. Once completed, the asthma action plan is given to the person with asthma andor their carer to keep. This child has the knowledge and skills to selfadminister quickrelief medicine at school or daycare with approval of the school nurse. My asthma action plan childrens healthcare of atlanta. Asthma action plans also tell school and other caregivers about your childs asthma. How frequently are you experiencing asthma symptoms.
If you do not have an asthma action plan, download and print this form. Asthma action plan new york state department of health. This could include teachers, school nurses, and after school care staff. An asthma action plan is a strategy that you can use to identify when your asthma may be flaring up and how to manage your asthma when it gets out of control. Asthma and allergy foundation of america 1235 south clark street suite 305, arlington, va 22202 phone. If the child is getting worse or is in the yellow zone for more than 24 hours, then follow the instructions in the red zone and call the doctor right away. Ask if you should change your child s asthma treatment plan.
Both the healthcare provider and the parentguardian feel that the child has demonstrated the skills to carry and selfadminister their quickre lief inhaler. Assess asthma severity to initiate treatment see page 5. Asthma treatment plan student parent instructions the pacnj asthma treatment plan is designed to help everyone understand the steps necessary for the individual student to achieve the goal of controlled asthma. Name asthma action plan, for children 6 years or older. Simply put, an asthma action plan provides the person with asthma andor their carer clear instructions on what to do when symptoms of asthma appear. San francisco bay area regional asthma management plan. The asthma action plan chosen should be appropriate for the persons age, treatment regimen, asthma severity, culture, language, literacy level, and ability to selfmanage. Perform spirometry at baseline and at least every 1 to 2 years for patients 5 years of age. Using an asthma action plan nationwide childrens hospital.
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