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Connecticut Department ofPublicHealth
Rev. 6/22/2012
Healthcare Provider Instructions for Completing the Asthma Action Plan
The purpose of this Asthma Action Plan (AAP) is to help families become proactive about gaining asthma control and anticipate triggers and symptoms indicative of an asthma exacerbation. The Asthma Action Plan is an educational and communication tool between the provider and the patient/family as well as other caregivers in childcare or school settings. The AAP is a tool to guide patients/families to support patient asthma self-management and the appropriate use of medicines. The Asthma Action Plan can provide clear guidance to the patient for self-management by:
1. Determining asthma control goals between the patient and provider. A date to accomplish it should be set. An example could be running a 5K or sleeping through the night for a week.
2. Identify all triggers. Discuss ways to reduce exposure to known triggers.
3. Determining treatment based on level of asthma severity. Address issues related
to asthma severity including: allergens, smoke, rhinitis, gastro esophageal reflux, sulfite sensitivity, medication interactions, and viral respiratory infections.
4. Providing a list of specific medications and dosages within each zone with
directions for how much to take and how often.
5. Zones: Green: List all daily medicines. It is generally expected that the patient should take their regular preventive (controller) medications, avoid triggers, and can exercise regularly.
Yellow: Add medicines that should be taken when asthma symptoms begin and instruct the patient to continue with green zone medicines. It is important to include how long to continue taking added medicines and when to contact the provider.
Red: List any medicines to be taken while waiting to speak to the provider or preparing to go to the emergency room. This zone guides immediate actions, need for close monitoring and notification of physician and parent, up to and including calling 911.
6. Review Action Steps. Review the entire plan with the family so they are clear on
how to adjust the medications, and when to call for help.
Connecticut Department of PublicHealth
Rev. 6/22/2012
7. Sign the form. Have the parent/guardian sign to allow for communication
between the provider and caregivers.
8. Distribute copies of the plan. To the family, to the school or day care, to other care givers and for your medical record.
9. Review the Asthma Action Plan regularly (Step up/step Down Therapy). The
plan should be updated every 6-12 months or when changes in treatment are made.
To receive additional copies of the Asthma Action Plan, contact the Connecticut Department of Public Health at (860) 509-8251.
Copies of the Asthma Action Plan may be downloaded as a fillable Adobe form, which can be modified to fit individual practice needs from the DPH website:www.ct.gov/dph/asthma.
10. How to use this form:
a) This form is meant to be completed on a computer and then saved and printed b) It can be prepopulated with standing orders, printed and then used for
individual patients or as a practice template c) The first block allows you to enter all patient/practice specific information d) The first block allows text entry for specific seasons and the other category e) Make sure to check severity and that only one block is checked f) Drop down boxes list specific medications and dosages g) The pediatric form lists medications by age groups 0-4 years and 5-11 years h) Directions are very specific and once selected can be added to with additional
typed text i) Any place there is a line for a drop down box text can be added if you don’t
wish to use the drop down box. j) Each category in the drop down boxes is customizable and can be modified or
deleted k) Once the form has been populated it can be saved and printed If a saved form
is opened to make a change, any specific field can be modified and then must be resaved and printed out depending on the changes made
l) Print outs can then be scanned into electronic health records m) To reduce typing, the Spanish version is linked to the English version so all
information entered in the English version populates the Spanish version at the same time. Just print out and/or save the English version if that is what is needed
Download a copy of the plan at http://www.ct.gov/dph/cwp/view.asp?a=3137&q=397020 For questions contact the Asthma Program at 860-509-8251.
Name: Birth Date: Date:
Parent/Guardian Phone #’s: Provider Phone #: Fax #: (or stamp)
Important! Things that make your asthma worse (Triggers): ☒ smoke ☐ pets ☐ mold ☐ dust ☐ tree/grass/weed pollen ☐ colds/viruses ☐ exercise ☐ seasons: other:
Severity Classification: ☐ Severe Persistent ☐ Moderate Persistent ☐ Mild Persistent ☐ Intermittent
Make an appointment with your primary care provider within two days of an emergency visit, hospitalization, or anytime for ANY problem or question with asthma School Nurse: Call provider for control concerns or if rescue medication is used more than 2 times/week for asthma symptoms
Parents: Call your doctor for control concerns or if rescue medication is used more than 2 times/week for asthma symptoms
HEALTHCARE PROVIDER SCHOOL MEDICATION AUTHORIZATION REQUIRED FOR ___________________as stated in accordance with CT State Law and Regulations 10-212a
Self–Administration: This student is capable to safely and properly self-administer this medication OR This student is not approved to self-administer this medication
Signature:_________________________________Provider Printed Name:___________________________Date:_____________ For use from ______ to ______
Parent/Guardian Consent: REQUIRED I authorize this medication to be administered by school personnel OR I authorize the student to possess and self-administer medication. I also authorize communication between the prescribing health care provider, the school nurse, the school medical advisor and school-based clinic providers necessary for asthma management and administration of this medication. Parent/Guardian Signature: ____________________________________ Date: _____________ * Bring asthma meds and spacer to all visits
You have any of these: First signs of a cold Exposure to known trigger Cough Wheeze Tight chest Coughing at night
Your asthma is getting worse fast: Medicine is not helping Breathing is hard and fast Nose opens wide Can’t talk well Getting nervous
GO – You’re Doing Well! USE THESE MEDICINES EVERY DAY TO PREVENT SYMPTOMS
CAUTION – Slow Down! Continue with Green Zone Medicine and Add:
DANGER – Get Help! TAKE THESE MEDICINES AND SEEK MEDICAL HELP NOW!
You have all of these: Breathing is good No cough or wheeze Sleep through the night Can work and play
CONTROLLER MEDICINE DIRECTIONS ___________________________________ ______________________________________ ___________________________________ ______________________________________
☐ If your child usually has symptoms with exercise then give: ___________________________________ ______________________________________ Inhalers work better with spacers. Always use with a mask when prescribed.
RESCUE MEDICINE DIRECTIONS _____________________________________ ______________________________________ Then: Wait 20 minutes and see if the treatment(s) helped
If you are GETTING WORSE or NOT IMPROVING after the treatment(s) GO TO RED ZONE If you are BETTER, continue treatments every 4 to 6 hours as needed for 24 to 48 hours
Then: If you still have symptoms after 24 hours, CALL YOUR DOCTOR and if he/she agrees: Start: ________________________________________________________________
If rescue medication is needed more than 2 times a week, call your doctor at: _______________________
RESCUE MEDICINE DIRECTIONS ______________________________________ _______________________________________ Then: Wait 15 minutes and see if treatment helped
If GETTING WORSE or NOT IMPROVING, go to the hospital or call 911 If you are getting BETTER, continue treatments every 4 to 6 hours and call your doctor – say you are
having an asthma attack and need to be seen TODAY! Then: If your doctor agrees, start: _________________________________________________
Peak Flow may be useful for some kids.
Asthma Action Plan Ages 0 – 11 Years
STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH
www.ct.gov/dph/asthma
STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH
www.ct.gov/dph/asthma
Nombre de paciente: Fecha de nacimiento: Fecha:
# teléfono del Padre/Guardián: # teléfono del Médico: # fax:
¡Importante! Cosas que hace peor el asma: □ humo □ mascotas □ moho □ polvo □ polen de árbol/hierba □ resfriado/virus □ ejercício □ cambio de clima: □ otras cosas:
Clasificación de Severidad: □ Severo persistente □ Moderado persistente □ Leve persistente □ Leve Intermitente
Haga una cita con su proveedor de cuidado primario dentro de dos días a partir de una visita al ED o una hospitalización, o en cualquier momento para cualquier problema o pregunta sobre asma.
School Nurse: Call provider for control concerns or if rescue medication is used more than 2 times/week for asthma symptoms Padre/Guardián: Llame al médico para discutir preguntas sobre control del asma o si uso de medicina de rescate es más que 2 veces/semana
HEALTHCARE PROVIDER SCHOOL MEDICATION AUTHORIZATION REQUIRED FOR ___________________as stated in accordance with CT State Law and Regulations 10-212a
Self–Administration: This student is capable to safely and properly self-administer this medication OR This student is not approved to self-administer this medication
Signature:_________________________________Provider Printed Name:___________________________Date:_____________ For use from ______ to ______
Padre/Guardián: OBLIGATARIO Autorizo al empleados medicos de la escuela para dar estas medicinas a mi niño/a O Autorizo al estudiante para tener estas medicinas y tomárselas a si mismo
Autorizo también la comunicación, entre el médico que prescribe las medicinas, la enfermera escolar, el consejero médico escolar, y professionales de clínica basados en la escuela que es necesario para el manejo de asma y administración de estas medicinas.
Firma del Padre/Guardián: ___________________________ Fecha: _____________ Traiga medicinas para asma y espaciador a todas citas.
Rápidamente, su asma está empeorando: La medicina no le ayuda Respiración es difícil y rápido Las fosas nasales se abre ancha No puede hablar bien Se pone nervioso
Si tiene estos sintomas: Síntomas iniciales del resfriado Contacto con alguna cosa que
provoca asma Tos Sibilancia Pecho apretado Tos por la noche
Usted tiene todos estos sintomas: Respira bien No hay tos o sibilancias Duerme toda la noche Puede trabajar y jugar
Proceda – ¡Está haciendo bien! USE ESTAS MEDICINAS CADA DÍA PARA PREVENIR SÍNTOMAS
PRECAUCIÓN – ¡Detengase! Continúe con medcina de la Zona Verde y Añade:
MEDICINA DE CONTROL COMO DEBERÍA TOMARLA ___________________________________ ______________________________________ ___________________________________ ______________________________________
☐ Si por lo general su niño tiene sÍntomas de asma durante el ejercicio, déle: ___________________________________ ______________________________________
Inhaladores funciona mejor con un espaciador. Siempre use con el espaciador con mascarilla o boquilla.
MEDICINA DE RESCATE COMO DEBERÍA TOMARLA
_____________________________________ ______________________________________ Entonces: Espere 20 minutos y evalúe si el tratamiento ayudó
Si ESTÁ EMPEORANDO o NO HAY MEJORÍA después del tratamiento, PROCEDA A LA ZONA ROJA Si HAY MEJORÍA, continúe con la medicina en dosis indicada cada 4 a 6 horas como necesario
durante 24 a 48 horas Entonces: Si todavía tiene síntomas despúes de 24 horas, LLAME A SU MÉDICO. Si él/ella está de acuerdo:
Empiece: ________________________________________________________________
Si necesita medicina de rescate más que dos veces en una semana, llame a su médico: _________________
MEDICINA DE RESCATE COMO DEBERÍA TOMARLA
______________________________________ _______________________________________ Entonces: Espere 15 minutos y evalúe si el tratamiento ayudó
Si ESTÁ EMPEORANDO o NO HAY MEJORÍA, vaya al hospital o llame 911 Si HAY MEJORÍA, continúe con la medicina en dosis indicada cada 4 a 6 horas y llame a su médico –
Dígale que está teniendo un ataque de asma y necesita una cita HOY! Entonces: Si él/ella está de acuerdo, empiece: _________________________________________________
Información sobre flujo máximo podría ser útil para niños que no
perciben bien sus síntomas.
Plan de Acción Contra el Asma Niños 0 – 11 años
PELIGRO – ¡Obtenga ayuda! TOME ÉSTAS MEDICINAS Y COJA AYUDA MEDICA AHORA MISMO!
Name: Birth Date: Date:
Parent/Guardian Phone #’s: Provider Phone #: Fax #: (or stamp)
Important! Things that make your asthma worse (Triggers): ☒ smoke ☐ pets ☐ mold ☐ dust ☐ tree/grass/weed pollen ☐ colds/viruses ☐ exercise ☐ seasons: other:
Severity Classification: ☐ Severe Persistent ☐ Moderate Persistent ☐ Mild Persistent ☐ Intermittent
Make an appointment with your primary care provider within two days of an emergency visit, hospitalization, or anytime for ANY problem or question with asthma School Nurse: Call provider for control concerns or if rescue medication is used more than 2 times/week for asthma symptoms
Parents: Call your doctor for control concerns or if rescue medication is used more than 2 times/week for asthma symptoms
HEALTHCARE PROVIDER SCHOOL MEDICATION AUTHORIZATION REQUIRED FOR ___________________as stated in accordance with CT State Law and Regulations 10-212a
Self–Administration: This student is capable to safely and properly self-administer this medication OR This student is not approved to self-administer this medication
Signature:_________________________________Provider Printed Name:___________________________Date:_____________ For use from ______ to ______
Parent/Guardian Consent: REQUIRED I authorize this medication to be administered by school personnel OR I authorize the student to possess and self-administer medication. I also authorize communication between the prescribing health care provider, the school nurse, the school medical advisor and school-based clinic providers necessary for asthma management and administration of this medication. Parent/Guardian Signature: ____________________________________ Date: _____________ * Bring asthma meds and spacer to all visits
You have any of these: First signs of a cold Exposure to known trigger Cough Wheeze Tight chest Coughing at night
Your asthma is getting worse fast: Medicine is not helping Breathing is hard and fast Nose opens wide Can’t talk well Getting nervous
GO – You’re Doing Well! USE THESE MEDICINES EVERY DAY TO PREVENT SYMPTOMS
CAUTION – Slow Down! Continue with Green Zone Medicine and Add:
DANGER – Get Help! TAKE THESE MEDICINES AND CALL YOUR PROVIDER NOW
You have all of these: Breathing is good No cough or wheeze Sleep through the night Can work and play
CONTROLLER MEDICINE DIRECTIONS _____________________________________ ______________________________________
_____________________________________ ______________________________________
☐ If you usually have symptoms with exercise then take:
_____________________________________ ______________________________________
Inhalers work better with spacers. Always use with a mask when prescribed.
RESCUE MEDICINE DIRECTIONS __________________________ ________________________________________ Then: Wait 20 minutes and see if the treatment(s) helped
If you are GETTING WORSE or are NOT IMPROVING after the treatment(s), go to the Red Zone If you are BETTER, continue treatments every 4 to 6 hours as needed for 24 to 48 hours
Then: If you still have symptoms after 24 hours, CALL YOUR DOCTOR and if he/she agrees: Start : _______________________________________
If rescue medication is needed more than 2 times a week, call your doctor at: _______________________
RESCUE MEDICINE DIRECTIONS _____________________________________ _________________________________________ Then: Wait 15 minutes and see if the treatment(s) helped
If you are GETTING WORSE or are NOT IMPROVING, go to the hospital or call 9‐1‐1 If you are BETTER, continue treatments every 4 to 6 hours and call your doctor – say you are having
an asthma attack and need to be seen TODAY Then: If your doctor agrees, start: _________________________________________________
Peak Flow may be useful for some kids.
Asthma Action Plan 12 Years & Older
STATE OF CONNECTICUTDEPARTMENT OF PUBLIC HEALTH
www.ct.gov/dph/asthma
STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH
www.ct.gov/dph/asthma
Nombre de paciente: Fecha de nacimiento: Fecha:
# teléfono del Padre/Guardián: # teléfono del Médico: # fax:
¡Importante! Cosas que hace peor el asma: □ humo □ mascotas □ moho □ polvo □ polen de árbol/hierba □ resfriado/virus □ ejercício □ cambio de clima: □ otras cosas:
Clasificación de gravedad: □ Grave persistente □ Moderado persistente □ Leve persistente □ Leve Intermitente
Haga una cita con su proveedor de cuidado primario dentro de dos días a partir de una visita al ED o una hospitalización, o en cualquier momento para cualquier problema o pregunta sobre asma.
School Nurse: Call provider for control concerns or if rescue medication is used more than 2 times/week for asthma symptoms Padre/Guardián: Llame al médico para discutir preguntas sobre control del asma o si uso de medicina de rescate es más que 2 veces/semana
HEALTHCARE PROVIDER SCHOOL MEDICATION AUTHORIZATION REQUIRED FOR ___________________as stated in accordance with CT State Law and Regulations 10-212a
Self–Administration: This student is capable to safely and properly self-administer this medication OR This student is not approved to self-administer this medication
Signature:_________________________________Provider Printed Name:___________________________Date:_____________ For use from ______ to ______
Padre/Guardián: OBLIGATARIO Autorizo al empleados medicos de la escuela para dar estas medicinas a mi niño/a O Autorizo al estudiante para tener estas medicinas y tomárselas a si mismo
Autorizo también la comunicación, entre el médico que prescribe las medicinas, la enfermera escolar, el consejero médico escolar, y professionales de clínica basados en la escuela que es necesario para el manejo de asma y administración de estas medicinas.
Firma del Padre/Guardián: ___________________________ Fecha: _____________ Traiga medicinas para asma y espaciador a todas citas.
Rápidamente, su asma está empeorando: La medicina no le ayuda Respiración es difícil y rápido Las fosas nasales se abren ancha No puede hablar bien Se pone nervioso
Si tiene estos síntomas: Síntomas iniciales del resfriado Contacto con alguna cosa que
provoca asma Tos Sibilancia Pecho apretado Tos por la noche
Usted tiene todos estos síntomas: Respira bien No hay tos o sibilancias Duerme toda la noche Puede trabajar y jugar
Proceda – ¡Está haciendo bien! USE ESTAS MEDICINAS CADA DÍA PARA PREVENIR SÍNTOMAS
PRECAUCIÓN – ¡Detengase! Continúe con medcina de la Zona Verde y Añade:
MEDICINA DE CONTROL COMO DEBERÍA TOMARLA ___________________________________ ______________________________________
___________________________________ ______________________________________ ☐ Si por lo general su niño tiene sÍntomas de asma durante el ejercicio, déle:
___________________________________ ______________________________________
Inhaladores funciona mejor con un espaciador. Siempre use el espaciador con una mascarilla.
MEDICINA DE RESCATE COMO DEBERÍA TOMARLA
_____________________________________ ______________________________________ Entonces: Espere 20 minutos y evalúe si el tratamiento ayudó
Si ESTÁ EMPEORANDO o NO HAY MEJORÍA después del tratamiento, PROCEDA A LA ZONA ROJA Si HAY MEJORÍA, continúe con la medicina en dosis indicada cada 4 a 6 horas como necesario
durante 24 a 48 horas Entonces: Si todavía tiene síntomas despúes de 24 horas, LLAME A SU MÉDICO. Si él/ella está de acuerdo:
Empiece: ________________________________________________________________
Si necesita medicina de rescate más que dos veces en una semana, llame a su médico: _________________
MEDICINA DE RESCATE COMO DEBERÍA TOMARLA
______________________________________ _______________________________________ Entonces: Espere 15 minutos y evalúe si el tratamiento ayudó
Si ESTÁ EMPEORANDO o NO HAY MEJORÍA, vaya al hospital o llame 911 Si HAY MEJORÍA, continúe con la medicina en dosis indicada cada 4 a 6 horas y llame a su médico –
Dígale que está teniendo un ataque de asma y necesita una cita HOY! Entonces: Si él/ella está de acuerdo, empiece: _________________________________________________
Información sobre flujo máximo podría ser útil para ellos que no
perciben bien sus síntomas.
Plan de Acción Contra el Asma Edad 12 años y más
PELIGRO – ¡Obtenga ayuda! TOME ÉSTAS MEDICINAS Y LLAME AYUDA MEDICA AHORA MISMO!