Dell Children’s Medical Center of Central Texas
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Central Texas Asthma Action Plan

To be completed by Physician Designee and signed by Physician
Patient Label Here
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The colors of a traffic light will help you use your asthma medicines.

Green = Go Zone!
Use preventive medicine.

Yellow = Caution Zone!
Add quick-relief medicine.

Red = Danger Zone!
Get help from a doctor.

Grade in School:           Date:   December 20, 2014

Has the patient ever been admitted to ICU?  Yes  No 
Has the patient ever required mechanical ventilation?   Yes  No

Please classify this patient’s asthma. Refer to these choices adopted from the NIH Asthma Management Guidelines.

Asthma Classification by Physician:
Intermittent         Moderate persistent
Mild persistent   Severe persistent

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PREDICTED NORMAL PEAK FLOW READING:
 lpm

Classification
Days with symptoms
Nights with symptoms
FEV1 or PEF (% pred. normal)
Severe persistent Continual Frequent ≤ 60%
Moderate persistent Daily ≥ 5/month > 60% to < 80%
Mild persistent > 2/week 3 to 4/month ≥ 80%
Intermittent ≤ 2/week ≤ 2/month ≥ 80
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GREEN ZONE: No signs or PF 80-100% of Predicted Normal or Personal Best – Take Preventative Medication
PEAK FLOW FROM lpm TO lpm

You have all of these:

  • Breathing is good
  • No cough or wheeze
  • Sleep through night
  • Can work and play
  1. What preventative medications are prescribed and how often are they given?
    Name and Dose:
  2. Does this patient have Exercised Induced Asthma? Yes No
    If yes, what medication should be given for EIA? Take only one of the treatments 15-20 minutes before physical activity as needed.
    ALBUTEROL 2 puffs MDI & chamber ALBUTEROL 1 vial in nebulizer
    XOPENEX 2 puffs MDI & chamber XOPENEX 1 vial in nebulizer
    OTHER:
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YELLOW ZONE: Caution Signs or PF 50-79% of Predicted Normal or Personal Best – Continue Preventative Medication
PEAK FLOW FROM lpm TO lpm

You have any of these:

  • First signs of a cold
  • Exposure to known trigger
  • Coughing doesn’t stop
  • Mild wheeze
  • Chest tightness
  1. In case of an asthma exacerbation, what quick-relief medication should be used? Take one treatment every 4-6 hours as needed for 24-48 hours. Recheck peak flow 15 minutes after treatment
    ALBUTEROL puffs MDI & chamber ALBUTEROL 1 vial in nebulizer
    XOPENEX puffs MDI & chamber XOPENEX 1 vial in nebulizer
    OTHER:

  2. If treatments are needed for longer than 24-48 hours, call your doctor.
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RED ZONE: Danger Signs or PF Below 50% of Predicted Normal or Personal Best – Continue Preventative Medication
PEAK FLOW BELOW lpm

Your asthma is getting worse fast:

  • Medicine isn’t helping
  • Breathing is hard and fast
  • Nose opens wide
  • Ribs show during breathing
  • Can’t talk well.
  • Inhale & exhale wheeze
  1. In case of an asthma exacerbation, what quick-relief medication should be used? Take one treatment every 20 minutes for up to three treatments only. Recheck peak flow 15 minutes after treatment
    ALBUTEROL puffs MDI & chamber ALBUTEROL 1 vial in nebulizer
    XOPENEX puffs MDI & chamber XOPENEX 1 vial in nebulizer
    OTHER:

  2. Get immediate medical attention – Call your doctor. If at school, go to the nurse. Or, call 911.
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Physician signature: ___________________________________ Physician name: ______________________________________

Telephone: (_______)______________________ Date: _________________

For children in school:    School Name: ____________________________ School district: ________________________________

I, the above signed physician, certify that the above named student has asthma and is capable of carrying and self-administering the above quick-relief asthma medication. (Texas Inhaler Law.)    (  ) Yes (  ) No

I give permission for the school nurse to administer the above physician orders and to communicate with my child’s health care provider concerning my child’s asthma.

Parent signature: ___________________________________ Parent name: ______________________________________

Telephone: (_______)______________________ Date: _________________

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Developed by the Central Texas Asthma Coalition for use by any Central Texas physician Based on 2002 NIH/NHLBI Guidelines for the Diagnosis and Management of Asthma. Rev. 4/5/2008

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ASTHMA TRIGGER CHECKLIST

Please have Patient/Caregiver check all that apply and review actions to take to avoid patient’s asthma triggers.

  • SECOND-HAND SMOKE
    • Don’t smoke in your home/car and don’t permit others to do so either.
    • Choose not to smoke in the presence of asthmatics.
    • Choose not to smoke in the presence of children susceptible to the effects of second-hand smoke.
    • Limit use of wood-burning stoves.
    • Do not allow your child around others who smoke.
  • MOLD
    • Wash mold off hard surfaces and dry completely.
    • Fix leaky plumbing or other sources of water.
    • Keep drip pans in air conditioner, refrigerator, and dehumidifier clean and dry.
    • Clean and service Heating/ AC regularly.
    • Maintain low indoor humidity between 30-50% relative humidity.
    • Keep away from basement or other damp places.
  • PETS
    • Keep pets out of the bedroom and other sleeping areas at all times.
    • Keep pets away from fabric-covered furniture, carpets and stuffed toys.
    • If pets are one of your child’s asthma triggers, strongly consider finding a new home for your pets.
  • DUST/DUST MITES
    • Wash bedding in hot water once a week.
    • Keep stuffed toys off beds. Choose washable stuffed toys, wash them often in hot water, and dry thoroughly.
    • Cover mattresses and pillows in dust-proof (allergen-impermeable) zippered covers.
    • Avoid feather and down bedding.
    • Consider removal of carpets and rugs.
    • Remove dust often with a damp cloth.
  • COLD/VIRAL INFECTIONS
    • Keep child away from people or other children who have a viral infection.
    • Be sure your child gets prompt treatment for cold symptoms and respiratory infections.
    • Keep age appropriate immunizations up to date and make sure everyone in the immediate family receive a Flu shot.
  • OZONE/POLLEN AND OTHER OUTDOOR IRRITANTS
    • Use Air Conditioner to avoid having to open windows, if possible.
    • Limit outdoor activities when reports indicate high pollen counts or Ozone Action Days.
    • In cold air, have child wear scarf around face to warm air going into lungs.
    • Dry clothing in dryer rather than hanging outside.
  • PESTS
    • Don’t leave out food or garbage.
    • Store foods in airtight containers.
    • Clean all food crumbs or spilled liquids right away.
    • Wash dishes as soon as possible.
    • Keep counters, sinks, tables, and floors clean/clear of clutter.
    • Store piles of boxes, newspapers, and other items outside home.
    • Make sure trash is properly stored in containers with lids and removed daily.
    • Try using baits, boric acid, or traps first before pesticidal sprays.
    • If spraying
      • Limit spraying to infested area.
      • Do not spray where you prepare/store food, or where children play, crawl, or sleep.
      • Follow instructions on label.
      • Make sure person with asthma is out of room while spraying.
      • Allow room to thoroughly air out after spraying.
  • FOOD ALLERGIES
    • Beware of foods that cause you breathing problems.
    • If you experience symptoms, avoid any further contact with that food item, rinse your mouth and see a doctor.
    • Learn to read food labels carefully.
    • If you have had a severe reaction to a food, talk to your doctor about carrying an epinephrine injector.
    • When dining out, asked about the ingredients used in preparing the dish before tasting the food.
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