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Asthmaaction

Asthma Action Plan
PROVIDER INSTRUCTIONS
At initial presentation, determine the level of asthma severity
Asthma severity and asthma
control include the domains

● Level of severity is determined by both impairment and risk and is assigned to the most severe category in which ➡any feature occurs.
of current impairment and
future risk.

At subsequent visits, assess control to adjust therapy
Impairment: frequency and
● Level of control is determined by both impairment and risk and is assigned to the most severe category in which any feature occurs.
● Address adherence to medication, inhaler technique, and environmental control ● Sample patient self-assessment tools for asthma control can be found at http://www.asthmacontrol.com/index.html
Risk: the likelihood of either
http://www.asthmacontrolcheck.com
asthma exacerbations, progressivedecline in lung function (or, forchildren, reduced lung growth), Stepwise approach for managing asthma:
or risk of adverse effects frommedication.
● Therapy is increased (stepped up) if necessary and decreased (stepped down) when possible as determined by the level of asthma severity or asthma control.
ASTHMA MANAGEMENT RECOMMENDATIONS:
HOW TO USE THE ASTHMA ACTION PLAN:
— Ensure that patient/family receive education about asthma Top copy (for patient):
and how to use spacers and other medication delivery devices.
● Enter specific medication information and review — Assess asthma control at every visit by self-administered the instructions with the patient and/or family.
standardized test or verbal history.
● Educate patient and/or family about factors that — Perform spirometry at baseline and at least every 1 to 2 years make asthma worse and the remediation steps — Update or review the Asthma Action Plan every 6 to 12 months.
Complete and sign the bottom of the form
and give this copy of the form to the patient.
— Perform skin or blood al ergy tests for al patients with Middle copy (for school, childcare, work, etc):
— Encourage patient/family to continue fol ow-up with their ● Educate the parent/guardian on the need for their clinician every 1 to 6 months even if asthma is wel control ed.
signature on the back of the form in order to authorize student self-carry and self-administration of asthma medications at school and also to ● there are difficulties achieving or maintaining control authorize sharing student health information step 4 care or higher is required (step 3 care or higher Provide this copy of the form to the
school/childcare center/work/caretaker or
other involved third party. (This copy may

● immunotherapy or omalizumab is considered OR also be faxed to the school, etc.)
Bottom copy (for chart):
● if the patient required 2 bursts of oral systemic corticosteroids in the past year or a hospitalization.
File this copy in the patient's medical chart.
FOR MORE INFORMATION:
To access the August 2007 full version of the NHLBI Guidelines for the Diagnosis and Treatment of Asthma (EPR-3)
or the October 2007 Summary Report, visit http://www.nhlbi.nih.gov/guidelines/asthma/index.htm.
THIS PAGE HAS BEEN INTENTIONALLY LEFT BLANK My Asthma Plan ENGLISH
Controller Medicines
How Much to Take
How Often
Other Instructions
EVERY DAY!
EVERY DAY!
EVERY DAY!
EVERY DAY!
Quick-Relief Medicines
How Much to Take
How Often
Other Instructions
❑ Albuterol (ProAir, Ventolin, Proventil) tions and discuss your treatment plan.
doing well, getting worse,
having a medical alert.
Doing well.
PREVENT asthma symptoms every day:
● No cough, wheeze, chest tightness, or shortness of Take my controller medicines (above) every day.
E ● Can do usual activities.
Peak Flow (for ages 5 and up):
is ______ or more. (80% or more of personal best) Avoid things that make my asthma worse.
Personal Best Peak Flow (for ages 5 and up): ______
Getting worse.
CAUTION. Continue taking every day controller medicines, AND:
Take___puffs or___one nebulizer treatment of quick relief medicine.
If I am not back in the Green Zone within 20-30 minutes take
● Cough, wheeze, chest tightness, shortness of breath, or ___more puffs or nebulizer treatments. If I am not back in the ● Waking at night due to asthma symptoms, or Green Zone within one hour, then I should:
● Can do some, but not all, usual activities.
Increase_____________________________________________ Add________________________________________________ Peak Flow (for ages 5 and up):
Call________________________________________________ ______ to ______(50 to 79% of personal best) Continue using quick relief medicine every 4 hours as needed.
Call provider if not improving in ______days.
Medical Alert
MEDICAL ALERT! Get help!
● Quick-relief medicines have not helped, or ● Symptoms are same or get worse after 24 hours Peak Flow (for ages 5 and up):
less than _________(50% of personal best) Danger! Get help immediately! Call 911 if trouble walking or talking due to shortness of breath or
if lips or fingernails are gray or blue. For child, call 911 if skin is sucked in around neck and ribs during breaths or
child doesn't respond normally.
Health Care Provider: My signature provides authorization for the above written orders. I understand that all procedures will be implemented in
accordance with state laws and regulations. Student may self carry asthma medications: ❑ Yes ❑ No self administer asthma medications: ❑ Yes ❑ No (This authorization is for a maximum of one year from signature date.) ______________________________________ ______________________________ ORIGINAL (Patient) / CANARY (School/Child Care/Work/Other Support Systems) / PINK (Chart) Controlling Things That Make Asthma Worse
SMOKE
• Do not smoke. Attend classes to help stop smoking.
• Do not allow smoking in the home or car. Remaining smoke smell can trigger asthma.
• Stay away from people who are smoking.
• If you smoke, smoke outside.
• Vacuum weekly with a vacuum with a high efficiency filter or a central vacuum.
Try to make sure people with asthma are not home during vacuuming.
• Remove carpet if possible. Wet carpet before removing and then dry floor completely.
• Damp mop floors weekly.
• Wash bedding and stuffed toys in hot water every 1-2 weeks. Freeze stuffed toys that • Cover mattresses and pillows in dust-mite proof zippered covers.
• Reduce clutter and remove stuffed animals, especially around the bed.
• Replace heating system filters regularly.
PESTS
• Do not leave food or garbage out. Store food in airtight containers.
• Try using traps and poison baits, such as boric acid for cockroaches. Instead of sprays/bombs, use baits placed away from children, such as behind refrigerator.
• Vacuum up cockroach bodies and fill holes in with caulking or copper wool.
• Fix leaky plumbing, roof, and other sources of water.
• Use exhaust fans or open windows for cross ventilation when showering or cooking.
• Clean mold off hard surfaces with detergent in hot water and scrub with stiff brush or cleaning pad, then rinse clean with water. Absorbent materials with mold may need to be replaced.
• Make sure people with asthma are not in the room when cleaning.
• Fix leaky plumbing or other sources of water or moisture.
ANIMALS
• Consider not having pets. Avoid pets with fur or feathers.
• Keep pets out of the bedroom of the person with asthma.
• Wash your hands and the hands of the person with asthma after petting animals.
ODORS/SPRAYS
• Avoid using strongly scented products, such as home deodorizers and incense, and perfumed laundry products and personal care products.
• Do not use oven/stove for heating.
• When cleaning, keep person with asthma away and don't use strong smelling cleaning products.
• Avoid aerosol products.
• Avoid strong or extra strength cleaning products.
• Avoid ammonia, bleach, and disinfectants.
POLLEN AND OUTDOOR MOLDS
• Try to stay indoors when pollen and mold counts are high.
• Keep windows closed during pollen season.
• Avoid using fans; use air conditioners.
COLDS/FLU
• Keep your body healthy with enough exercise and sleep.
• Avoid close contact with people who have colds.
• Wash your hands frequently and avoid touching your hands to your face.
• Get an annual flu shot.
WEATHER AND AIR POLLUTION
• If cold air is a problem, try breathing through your nose rather than your mouth and covering up with a scarf.
• Check for Spare the Air days and nights and avoid strenuous exercise at those times.
• On very bad pollution days, stay indoors with windows closed.
EXERCISE
• Warm up before exercising.
• Plan alternate indoor activities on high pollen or pollution days.
• If directed by physician, take medication before exercise. (See Green Zone of Asthma Action Plan.) My Asthma Plan ENGLISH
Controller Medicines
How Much to Take
How Often
Other Instructions
EVERY DAY!
EVERY DAY!
EVERY DAY!
EVERY DAY!
Quick-Relief Medicines
How Much to Take
How Often
Other Instructions
❑ Albuterol (ProAir, Ventolin, Proventil) tions and discuss your treatment plan.
doing well, getting worse,
having a medical alert.
Doing well.
PREVENT asthma symptoms every day:
● No cough, wheeze, chest tightness, or shortness of Take my controller medicines (above) every day.
E ● Can do usual activities.
Peak Flow (for ages 5 and up):
is ______ or more. (80% or more of personal best) Avoid things that make my asthma worse.
Personal Best Peak Flow (for ages 5 and up): ______
Getting worse.
CAUTION. Continue taking every day controller medicines, AND:
Take___puffs or___one nebulizer treatment of quick relief medicine.
If I am not back in the Green Zone within 20-30 minutes take
● Cough, wheeze, chest tightness, shortness of breath, or ___more puffs or nebulizer treatments. If I am not back in the ● Waking at night due to asthma symptoms, or Green Zone within one hour, then I should:
● Can do some, but not all, usual activities.
Increase_____________________________________________ Add________________________________________________ Peak Flow (for ages 5 and up):
Call________________________________________________ ______ to ______(50 to 79% of personal best) Continue using quick relief medicine every 4 hours as needed.
Call provider if not improving in ______days.
Medical Alert
MEDICAL ALERT! Get help!
● Quick-relief medicines have not helped, or ● Symptoms are same or get worse after 24 hours Peak Flow (for ages 5 and up):
less than _________(50% of personal best) Danger! Get help immediately! Call 911 if trouble walking or talking due to shortness of breath or
if lips or fingernails are gray or blue. For child, call 911 if skin is sucked in around neck and ribs during breaths or
child doesn't respond normally.
Health Care Provider: My signature provides authorization for the above written orders. I understand that all procedures will be implemented in
accordance with state laws and regulations. Student may self carry asthma medications: ❑ Yes ❑ No self administer asthma medications: ❑ Yes ❑ No (This authorization is for a maximum of one year from signature date.) ______________________________________ ______________________________ ORIGINAL (Patient) / CANARY (School/Child Care/Work/Other Support Systems) / PINK (Chart) SCHOOL AUTHORIZATION FORM
To be completed by Parent/Guardian and turned in to the school
AUTHORIZATION AND DISCLAIMER FROM PARENT/GUARDIAN: I request that the school assist my child with the asthma medications
listed on this form, and the Asthma Action Plan, in accordance with state laws and regulations.
Yes No.
My child may carry and self-administer asthma medications and I agree to release the school district and school personnel from all claims ofliability if my child suffers any adverse reactions from self-administration of asthma medications: ❏ Yes No.
____________________________________________________ AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH INFORMATION TO SCHOOL DISTRICTS
Completion of this document authorizes the disclosure and/or use of individually identifiable health information, as set forth below, consistent with Federal laws (including HIPAA) concerning the privacy of such information. Failure to provide all information requested USE AND DISCLOSURE INFORMATION:
Patient/Student Name: ______________________________________________________ / __________________________ I, the undersigned, do hereby authorize (name of agency and/or health care providers): (1)__________________________________________ (2) ____________________________________________ to provide health information from the above-named child's medical record to and from: ______________________________________________ _________________________________________ School or school district to which disclosure is made Address / City and State / Zip Code __________________________________________ _________________________________________ Contact person at school or school district Area Code and Telephone Number The disclosure of health information is required for the following purpose:___________________________________________________________________________________________Requested information shall be limited to the following: ❏ All health information; or ❏ Disease-specific information as described:___________________________________________________________________________________________ DURATION:
This authorization shall become effective immediately and shall remain in effect until ___________(enter date) or for one year from the date of signature, if no date entered.
RESTRICTIONS:
Law prohibits the Requestor from making further disclosure of my health information unless the Requestor obtains another authorization form from me or unless such disclosure is specifically required or permitted by law.
YOUR RIGHTS:
I understand that I have the following rights with respect to this Authorization: I may revoke this Authorization at any time. My revocation must be in writing, signed by me or on my behalf, and delivered to the health care agencies/persons listed above. My revocation will be effective upon receipt, but will not be effective to the extent that the Requestor or others have acted in reliance to this Authorization.
RE-DISCLOSURE:
I understand that the Requestor (School District) will protect this information as prescribed by the Family Equal Rights Protection Act (FERPA) and that the information becomes part of the student's educational record. The information will be shared with individuals working at or with the School District for the purpose of providing safe, appropriate, and least restrictive educational settings and school health services I have a right to receive a copy of this Authorization. Signing this Authorization may be required in order for this student to obtain appropri-ate services in the educational setting.
APPROVAL: ______________________________
____________________________ ___________________ Printed Name Signature Date___________________________________ Relationship to Patient/Student Area Code and Telephone Number My Asthma Plan ENGLISH
Controller Medicines
How Much to Take
How Often
Other Instructions
EVERY DAY!
EVERY DAY!
EVERY DAY!
EVERY DAY!
Quick-Relief Medicines
How Much to Take
How Often
Other Instructions
❑ Albuterol (ProAir, Ventolin, Proventil) tions and discuss your treatment plan.
doing well, getting worse,
having a medical alert.
Doing well.
PREVENT asthma symptoms every day:
● No cough, wheeze, chest tightness, or shortness of Take my controller medicines (above) every day.
E ● Can do usual activities.
Peak Flow (for ages 5 and up):
is ______ or more. (80% or more of personal best) Avoid things that make my asthma worse.
Personal Best Peak Flow (for ages 5 and up): ______
Getting worse.
CAUTION. Continue taking every day controller medicines, AND:
Take___puffs or___one nebulizer treatment of quick relief medicine.
If I am not back in the Green Zone within 20-30 minutes take
● Cough, wheeze, chest tightness, shortness of breath, or ___more puffs or nebulizer treatments. If I am not back in the ● Waking at night due to asthma symptoms, or Green Zone within one hour, then I should:
● Can do some, but not all, usual activities.
Increase_____________________________________________ Add________________________________________________ Peak Flow (for ages 5 and up):
Call________________________________________________ ______ to ______(50 to 79% of personal best) Continue using quick relief medicine every 4 hours as needed.
Call provider if not improving in ______days.
Medical Alert
MEDICAL ALERT! Get help!
● Quick-relief medicines have not helped, or ● Symptoms are same or get worse after 24 hours Peak Flow (for ages 5 and up):
less than _________(50% of personal best) RED Danger! Get help immediately! Call 911 if trouble walking or talking due to shortness of breath or
if lips or fingernails are gray or blue. For child, call 911 if skin is sucked in around neck and ribs during breaths or
child doesn't respond normally.
Health Care Provider: My signature provides authorization for the above written orders. I understand that all procedures will be implemented in
accordance with state laws and regulations. Student may self carry asthma medications: ❑ Yes ❑ No self administer asthma medications: ❑ Yes ❑ No (This authorization is for a maximum of one year from signature date.) ______________________________________ ______________________________ ORIGINAL (Patient) / CANARY (School/Child Care/Work/Other Support Systems) / PINK (Chart) This Asthma Plan was developed by a committee facilitated by the Regional Asthma Management and Prevention (RAMP) Initiative, a program of the Public Health Institute. This publication was supported by Cooperative Agreement Number 1U58DP001016-01 from the Centers for Disease Control and Prevention. Its contents are solely the responsibility of the authorsand do not necessarily represent the official views of CDC. This plan is based on the recommendations from the National Heart, Lung, and Blood Institute's, “Guidelines for the Diagnosis and Management of Asthma,” NIH Publication No. 07-4051 (August 2007).
The information contained herein is intended for the use and convenience of physicians and other medical personnel and may not be appropriate for use in all circumstances. Decisions to adopt any particular recommendation must be made by qualified medical personnel in light of available resources and the circumstances presented by individual patients. No entity or individual involved in the funding or development of this plan makes any warranty or guarantee, express or implied, of the quality, fitness, performance or results of use of the information or products described in the plan or the Guidelines.
For additional information, please contact RAMP at (510) 302-3365, http://www.rampasthma.org.

Source: http://familydoctor.org/dam/familydoctor/documents/asthma_action_plan.pdf

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