Asthma Needs YOUR Action!
PLAN FOR CONTROL
See Your Doctor
• Have your doctor fill out a written asthma
treatment plan for you to take home.
• Understand your plan – ask questions,
talk about concerns including medication
side effects
• See your doctor regularly and keep all
appointments, even if you don’t feel sick
See Your School Nurse
• NJ law says you can carry your inhaler in
school with an asthma treatment plan on file
• Take a copy of your written asthma treatment
plan to your school nurse
Remember, Control is the Goal
AVOID TRIGGERS
Control Your Environment
•Know your asthma triggers
•Take action plan to avoid or reduce them
COMMUNICATE YOUR NEEDS
Ask About Your Health Insurance
•Call your insurance company to find out what
services, medications, and equipment are
covered for asthma
ASTHMA FACTS
ASTHMA ACTIONS
Your
Pathway to
Asthma
Control
Starts Here
Asthma is:
- Swollen airways
- Increased mucus in lungs
- Muscle spasm around the airways
• Asthma is a serious, chronic disease that
usually does not go away.
• Asthma needs on-going medical care.
• If you have any symptoms or need your
“quick-relief” medicine more than
2 times a week, your asthma is out of control
and you need a long-term control medication.
Call your doctor.
• Asthma needs action, pay attention to all
symptoms. Even mild symptoms are a signal
for action.
Learn More About Asthma
Talk to:
•Your doctor
•Your school nurse
•Your respiratory therapist
•Your insurance company
Attend:
•Asthma Education Programs
AND CONTACT
The Pediatric/Adult Asthma
Coalition of New Jersey
“Your Pathway to Asthma Control”
www.pacnj.org
The Pediatric/Adult Asthma Coalition of New Jersey, sponsored by the American Lung Association in
New Jersey, and this publication are supported by a grant from the New Jersey Department of Health
and Senior Services (NJDHSS), with funds provided by the U.S. Centers for Disease Control and
Prevention (USCDCP) under Cooperative Agreement 1U59EH000491-01. Its contents are solely the
responsibility of the authors and do not necessarily represent the official views of the NJDHSS or the
USCDCP. Although this document has been funded wholly or in part by the United States Environmental
Protection Agency under Agreement XA97250908-2 to the American Lung Association in New Jersey, it
has not gone through the Agency's publications review process and therefore, may not necessarily reflect
the views of the Agency and no official endorsement should be inferred. Information in this publication is
not intended to diagnose health problems or take the place of medical advice. For asthma or any medical
condition, seek medical advice from your child's or your health care professional.
ASTHMA NEEDS
PAC ACTION!
Start Now
Plan for Control
Avoid Triggers
Communicate Your Needs
Visit: www.pacnj.org
Follow Your Asthma Treatment Plan: It is YOUR Pathway to Asthma Control
Sponsored by
(This asthma action plan meets NJ Law N.J.S.A. 18A:40-12.8) (Physician’s Orders)
Doctor
Date of Birth
Parent/Guardian (if applicable)
Phone
«
HEALTHY
You have all of these:
• Breathing is good
• No cough or wheeze
• Sleep through
the night
• Can work, exercise,
and play
And/or Peak flow above _______
Phone
Effective Date
Emergency Contact
Phone
Take daily medicine(s). Some metered dose inhalers
may be more effective with a “spacer” – use if directed.
MEDICINE
HOW MUCH to take and HOW OFTEN to take it
䡺 Advair ® 䡺 100, 䡺 250, 䡺 500 __________1 inhalation twice a day
䡺 Advair ® HFA 䡺 45, 䡺 115, 䡺 230 ________2 puffs MDI twice a day
䡺 Alvesco® 䡺 80, 䡺 160 __________________䡺 1, 䡺 2 puffs MDI twice a day
䡺 Asmanex ® Twisthaler ® 䡺 110, 䡺 220 ______䡺 1, 䡺 2 inhalations 䡺 once or 䡺 twice a day
䡺 Flovent ® 䡺 44, 䡺 110, 䡺 220 ___________2 puffs MDI twice a day
䡺 Flovent ® Diskus® 䡺 50 䡺 100 䡺 250 _____1 inhalation twice a day
䡺 Pulmicort Flexhaler ® 䡺 90, 䡺 180________䡺 1, 䡺 2 inhalations 䡺 once or 䡺 twice a day
䡺 Pulmicort Respules® 䡺 0.25, 䡺 0.5, 䡺 1.0 __1 unit nebulized 䡺 once or 䡺 twice a day
䡺 Qvar ® 䡺 40, 䡺 80 ____________________䡺 1, 䡺 2 puffs MDI twice a day
䡺 Singulair 䡺 4, 䡺 5, 䡺 10 mg____________1 tablet daily
䡺 Symbicort ® 䡺 80, 䡺 160 _______________䡺 1, 䡺 2 puffs MDI twice a day
䡺 Other
䡺 None
Remember to rinse your mouth after taking inhaled medicine.
If exercise triggers your asthma, take this medicine_____________________ ____minutes before exercise.
GREEN IS THE GOAL
Continue daily medicine(s) and add fast-acting medicine(s).
You have any of these:
• Exposure to known trigger
• Cough
• Mild wheeze
• Tight chest
• Coughing at night
• Other:___________
«
And/or Peak flow from______ to______
EMERGENCY
Your asthma is
getting worse fast:
• Fast-acting medicine did not
help within 15-20 minutes
• Breathing is hard and fast
• Nose opens wide
• Ribs show
• Trouble walking and talking
• Lips blue • Fingernails blue
And/or Peak flow below _______
The Pediatric/Adult Asthma Coalition of New Jersey, sponsored by the American
Lung Association of New Jersey, and this publication are supported by a grant
from the New Jersey Department of Health and Senior Services (NJDHSS), with
funds provided by the U.S. Centers for Disease Control and Prevention (USCDCP)
under Cooperative Agreement 5U59EH000206-3. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of
the NJDHSS or the USCDCP.
Although this document has been funded wholly or in part by the
United States Environmental Protection Agency under Agreement
XA97256707-2 to the American Lung Association of New Jersey, it has
not gone through the Agency’s publications review process and therefore, may not necessarily reflect the views of the Agency and no official
endorsement should be inferred.
MEDICINE
HOW MUCH to take and HOW OFTEN to take it
䡺 Accuneb® 䡺 0.63, 䡺 1.25 mg _________1 unit nebulized every 4 hours as needed
䡺 Albuterol 䡺 1.25, 䡺 2.5 mg ___________1 unit nebulized every 4 hours as needed
䡺 Albuterol 䡺 Pro-Air 䡺 Proventil ® _______2 puffs MDI every 4 hours as needed
䡺 Ventolin ® 䡺 Maxair 䡺 Xopenex ® _______2 puffs MDI every 4 hours as needed
䡺 Xopenex ® 䡺 0.31, 䡺 0.63, 䡺 1.25 mg __1 unit nebulized every 4 hours as needed
䡺 Increase the dose of, or add:
䡺 Other
fast-acting medicine is needed more than 2 times a week,
¬ Ifexcept
before exercise, then call your doctor.
Triggers
Check all items
that trigger
patient’s asthma:
J Chalk dust
J Cigarette Smoke
& second hand
smoke
J Colds/Flu
J Dust mites,
dust, stuffed
animals, carpet
J Exercise
J Mold
J Ozone alert days
J Pests - rodents &
cockroaches
J Pets - animal
dander
J Plants, flowers,
cut grass, pollen
J Strong odors,
perfumes, cleaning products,
scented products
J Sudden temperature change
J Wood Smoke
J Foods:
J Other:
Take these medicines NOW and call 911.
Asthma can be a life-threatening illness. Do not wait!
䡺 Accuneb® 䡺 0.63, 䡺 1.25 mg _________1 unit nebulized every 20 minutes
䡺 Albuterol 䡺 1.25, 䡺 2.5 mg ___________1 unit nebulized every 20 minutes
䡺 Albuterol 䡺 Pro-Air 䡺 Proventil ® _______2 puffs MDI every 20 minutes
䡺 Ventolin ® 䡺 Maxair 䡺 Xopenex ® _______2 puffs MDI every 20 minutes
䡺 Xopenex ® 䡺 0.31, 䡺 0.63, 䡺 1.25 mg __1 unit nebulized every 20 minutes
䡺 Other
This asthma
treatment plan is
meant to assist,
not replace, the
clinical decisionmaking required
to meet individual
patient needs.
FOR MINORS ONLY:
䡺 This student is capable and has been instructed in the
proper method of self-administering of the non-nebulized
inhaled medications named above in accordance with
NJ Law.
PHYSICIAN/APN/PA SIGNATURE______________________________ DATE__________
PARENT/GUARDIAN SIGNATURE______________________________
PHYSICIAN STAMP
REVISED MAY 2009
䡺 This student is not approved to self-medicate.
Permission to reproduce blank form
www.pacnj.org
Make a copy for patient and for physician file. For children under 18, send original to school nurse or child care provider.
Approved PACNJ Asthma Treatment Plan
available at www.pacnj.org/plan.html
This is where you belong.
You are IN THE GREEN
when you:
•Sleep through the night
•Play sports
•Attend school and/or work
•Breathe without coughing
or wheezing
•Have peak flow rates in the green
Take action to
STAY IN THE GREEN:
Follow your asthma treatment plan:
•Take all daily medications that your
doctor prescribed in the green zone
•Avoid your triggers
•Monitor your peak flow
If you need your “quick relief” medicine,
go to the yellow zone.
YELLOW MEANS CAUTION
(Please Print)
Name
This CAUTION ZONE means
something has changed. You
are in THE YELLOW ZONE
when you have any of
these symptoms:
•Begin to cough or wheeze
•Feel tightness in your chest
•Begin coughing at night
•Are tired or unable to play
•Have a drop in your peak flow rates
Take action to get back
TO THE GREEN:
•Take the medications your doctor
prescribed in the yellow zone
for as long as indicated
•Continue with the medication prescribed in
the green zone as directed by
your doctor
•Get away from your triggers
•Monitor your peak flow
•Tell your parents and school nurse you
are in the yellow zone
If you DO NOT
FEEL BETTER in
15-20 minutes,
you may be headed
for THE RED ZONE.
RESCUE THE RED
Asthma Treatment Plan
This is the EMERGENCY ZONE.
You are in THE RED ZONE
when you have any ONE
of these symptoms:
•Your asthma is getting worse
•You are very short of breath,
breathing fast and hard
•Your medicine is not working
•You have trouble walking and talking
•Your fingernails and lips are turning blue
•You sense that something is very wrong
•Your peak flow rate is in the red
TAKE IMMEDIATE ACTION
• Take the medication
prescribed by your
doctor in the red zone
• See a doctor or go to
the Emergency Room
• Do not wait, this is serious