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Fill in the numeric values for peak flow readings (not percentages). Use the table below to determine 50% and 80% of personal best peak flow readings.
100%
GREEN ZONE: List all daily medications and corresponding directions in the appropriate boxes.
The Green Zone is 100% to 80% of personal best, or when the patient is free of symptoms.
80%
50%
YELLOW ZONE: Instruct the patient to continue taking Green Zone medications and to take all medications listed in the Yellow Zone. The Yellow Zone is 79% to 50% of personal best, or when the patient experiences symptoms listed in the Yellow Zone. It is important to indicate the duration of time that the patient should continue taking these medications and at what point he or she should contact you. RED ZONE: List any medications that the patient should take before contacting you or while preparing to go to the emergency room. The Red Zone is less than 50% of personal best, or when the patient experiences symptoms listed in the Red Zone.
Patients aged 5 years may use peak flow meters to monitor their asthma. Parents of children aged <5 years should use the symptoms listed on the ASMA Plan to determine their childs zone. Personal best peak flow should be determined when the patient is symptom free. A diary, which is usually a part of the peak flow meter package, can be used to record personal best. For children, it is a good idea to obtain a peak flow reading at all asthma visits and reestablish personal best regularly. Calculations Green Zone Yellow Zone Red Zone Personal Best (PB) Calculate 80% of Personal Best Calculate 50% of Personal Best PB x 0.8 = PB x 0.5 = Peak Flow Values
Even if you do not have symptoms, take these long-term control medicines each day.
Medicine How much to take When to take it
(Dose)
First
Add quick-relief medicine and keep taking your GREEN ZONE medicine.
________________________________________ q 2 to ___ puffs every ___ minutes for ___ treatments or (short-acting 2-agonist) q nebulizer treatments If your symptoms (and peak flow, if used) return to the GREEN ZONE after 1 hour of above treatment: Continue monitoring to be sure you stay in the GREEN ZONE.
second
or
Peak flow: __________ to ____________ (L/min) (50%79% of my best peak flow)
or
If your symptoms (and peak flow, if used) do not return to the GREEN ZONE after 1 hour of above treatment: q Take _________________________________ q 2 or q 4 puffs or q nebulizer every________ hours.
(short-acting 2-agonist) (oral steroid)
q Add _________________________________ _________ mg per day for_________ (310) days. q Add _________________________________________________________ per day for_________ days. q Call the health care provider q before or q within________ hours after taking the oral steroid.
Signs and symptoms n Very short of breath or n Quick-relief medicines have not helped or n Cannot do usual activities or n Symptoms are the same or worse after 24 hours in YELLOWZONE
q ______________________________________
q 4 or q 6 puffs or q nebulizer
q ______________________________________ _________ mg
or
Peak flow: less than _________________ (L/min) (less than 50% of my best peak flow)
Call your health care provider NOW. Go to the hospital or call for an ambulance if: n You are still in the REDZONE after 15 minutes AND n You have not reached your health care provider
DANGER SIGNS
n Trouble walking and talking due to shortness of breath n Take q 4 or q 6 puffs of your quick-relief medicine AND n Lips or fingernails are blue n Go to the hospital or call for an ambulance (___________________________ ) _
NOW!
People who should have a copy of my A.S.M.A. plan: spouse, school nurse, coworkers, babysitter, family members, friends.
Adapted from National Heart, Lung, and Blood Institute. Asthma Action Plan. Bethesda, MD: US Dept of Health and Human Services: April 2007. NIH publication 07-5251.
Patient copy
n Avoid cigar and cigarette SMOKE as much as possible. n Avoid strong ODORS, such as paint, perfume, and hair spray. n Wear a scarf or a COLD AIR mask over your mouth when its cold outside.
Even if you do not have symptoms, take these long-term control medicines each day.
Medicine How much to take When to take it
(Dose)
First
Add quick-relief medicine and keep taking your GREEN ZONE medicine.
________________________________________ q 2 to ___ puffs every ___ minutes for ___ treatments or (short-acting 2-agonist) q nebulizer treatments If your symptoms (and peak flow, if used) return to the GREEN ZONE after 1 hour of above treatment: Continue monitoring to be sure you stay in the GREEN ZONE.
second
or
Peak flow: __________ to ____________ (L/min) (50%79% of my best peak flow)
or
If your symptoms (and peak flow, if used) do not return to the GREEN ZONE after 1 hour of above treatment: q Take _________________________________ q 2 or q 4 puffs or q nebulizer every________ hours.
(short-acting 2-agonist) (oral steroid)
q Add _________________________________ _________ mg per day for_________ (310) days. q Add _________________________________________________________ per day for_________ days. q Call the health care provider q before or q within________ hours after taking the oral steroid.
Signs and symptoms n Very short of breath or n Quick-relief medicines have not helped or n Cannot do usual activities or n Symptoms are the same or worse after 24 hours in YELLOWZONE
q ______________________________________
q 4 or q 6 puffs or q nebulizer
q ______________________________________ _________ mg
or
Peak flow: less than _________________ (L/min) (less than 50% of my best peak flow)
Call your health care provider NOW. Go to the hospital or call for an ambulance if: n You are still in the REDZONE after 15 minutes AND n You have not reached your health care provider
DANGER SIGNS
n Trouble walking and talking due to shortness of breath n Take q 4 or q 6 puffs of your quick-relief medicine AND n Lips or fingernails are blue n Go to the hospital or call for an ambulance (___________________________ ) _
NOW!
People who should have a copy of my A.S.M.A. plan: spouse, school nurse, coworkers, babysitter, family members, friends.
Adapted from National Heart, Lung, and Blood Institute. Asthma Action Plan. Bethesda, MD: US Dept of Health and Human Services: April 2007. NIH publication 07-5251.
copy
I, (parent or guardian), hereby authorize that the following steps be taken in conjunction with the attached Asthma Action Plan:
q q q
Date
y child, M , may carry and self-administer medications as outlined in the Asthma Action Plan, consistent with policies, for a period not to exceed 1 year. School district/child care personnel may assist my child with use and interpretation of the Asthma Action Plan, consistent with policies, for a period not to exceed 1 year. School district/child care personnel may administer medications to my child as outlined in the Asthma Action Plan, consistent with policies, for a period not to exceed 1 year.
Even if you do not have symptoms, take these long-term control medicines each day.
Medicine How much to take When to take it
(Dose)
First
Add quick-relief medicine and keep taking your GREEN ZONE medicine.
________________________________________ q 2 to ___ puffs every ___ minutes for ___ treatments or (short-acting 2-agonist) q nebulizer treatments If your symptoms (and peak flow, if used) return to the GREEN ZONE after 1 hour of above treatment: Continue monitoring to be sure you stay in the GREEN ZONE.
second
or
Peak flow: __________ to ____________ (L/min) (50%79% of my best peak flow)
or
If your symptoms (and peak flow, if used) do not return to the GREEN ZONE after 1 hour of above treatment: q Take _________________________________ q 2 or q 4 puffs or q nebulizer every________ hours.
(short-acting 2-agonist) (oral steroid)
q Add _________________________________ _________ mg per day for_________ (310) days. q Add _________________________________________________________ per day for_________ days. q Call the health care provider q before or q within________ hours after taking the oral steroid.
Signs and symptoms n Very short of breath or n Quick-relief medicines have not helped or n Cannot do usual activities or n Symptoms are the same or worse after 24 hours in YELLOWZONE
q ______________________________________
q 4 or q 6 puffs or q nebulizer
q ______________________________________ _________ mg
or
Peak flow: less than _________________ (L/min) (less than 50% of my best peak flow)
Call your health care provider NOW. Go to the hospital or call for an ambulance if: n You are still in the REDZONE after 15 minutes AND n You have not reached your health care provider
DANGER SIGNS
n Trouble walking and talking due to shortness of breath n Take q 4 or q 6 puffs of your quick-relief medicine AND n Lips or fingernails are blue n Go to the hospital or call for an ambulance (___________________________ ) _
NOW!
People who should have a copy of my A.S.M.A. plan: spouse, school nurse, coworkers, babysitter, family members, friends.
Adapted from National Heart, Lung, and Blood Institute. Asthma Action Plan. Bethesda, MD: US Dept of Health and Human Services: April 2007. NIH publication 07-5251.
q q q q
q q q q
o you have asthma symptoms (such as coughing, wheezing, D breathlessness, or chest tightness) more than 2 days a week? Do you have to use your rescue inhaler or nebulizer medication more than 2 days a week? Does your asthma keep you from getting as much done as you would like at work, school, or home? Are you waking up at night because of asthma symptoms more than 2 times a month?
If you answered Yes to any of these questions, your asthma may not be under control. You should discuss your answers with your health care provider.