My Asthma Action Plan

Overview

  • My name ______________________________________
  • Doctor's name _________________________________
  • Doctor's phone ________________________________
Controller medicine How much? How often? Other instructions
Quick-relief medicine How much? How often? Other instructions

Important

EMERGENCY: If it's hard to walk or talk because of shortness of breath or if your lips or fingertips are blue, CALL 911 or go to the hospital for help right away.

GREEN ZONE This is where I want to be! YELLOW ZONE My asthma is getting worse. RED ZONE Danger!

Symptoms

  • I have no shortness of breath, cough, wheezing, or chest tightness.
  • I can do all of my usual activities.
  • I sleep well at night.

Symptoms

  • I'm coughing or wheezing or have chest tightness or shortness of breath.
  • Symptoms keep me up at night.
  • I can do some but not all of my usual activities.

Symptoms

  • I'm very short of breath.
  • I can't do my usual activities.
  • Quick-relief medicine doesn't help, or my symptoms don't get better after 24 hours in the yellow zone.

Peak flow (if I use a peak flow meter)

  • _________ or more (80% or more of my personal best)

Peak flow (if I use a peak flow meter)

  • ______ to ____ (50% to 79% of my personal best)

Peak flow (if I use a peak flow meter)

  • _____ or lower (less than 50% of my personal best)

Actions

  • [ ] Take controller medicine(s) every day.
  • [ ] Avoid asthma triggers.
  • [ ] ____ minutes before exercise, take quick-relief medicine called ________________.

Actions

  • [ ] Take _____ puff(s) of my quick-relief medicine called ________________. Repeat ____ times.
  • [ ] If my symptoms don't get better or my peak flow has not returned to the green zone in 1 hour, then:
    • [ ] Take _____ puff(s) of my medicine called ________________. Take it ___ times a day.
    • [ ] Begin or increase treatment with corticosteroid pills. Take ______ mg of ________________ every _______________.
    • [ ] Call my doctor at _______________.

Actions

  • [ ] Take _____ puff(s) of my quick-relief medicine called _____________. Repeat _____ times.
  • [ ] Begin or increase treatment with corticosteroid pills. Take ________ mg now.
  • [ ] Call my doctor at ______________. If I cannot contact my doctor, I need to go to the emergency department or call for help right away.
  • [ ] Other numbers I might call are ______________, ______________, ______________.

Current as of: July 31, 2024

Author: Ignite Healthwise, LLC Staff

Clinical Review Board
All Ignite Healthwise, LLC education is reviewed by a team that includes physicians, nurses, advanced practitioners, registered dieticians, and other healthcare professionals.

 

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