Asthma Action Plan, Adult

Patient Name: __________________________________________________ Date: ________

Follow-up appointment with physician:

  • Physician Name: ____________________

  • Telephone: ____________________

  • Follow-up recommendation: ____________________

Always take all of your medicines to all of your appointments.

POSSIBLE TRIGGERS

  • Animal dander from the skin, hair, or feathers of animals.

  • Dust mites contained in house dust.

  • Cockroaches.

  • Pollen from trees or grass.

  • Mold.

  • Cigarette or tobacco smoke.

  • Air pollutants such as dust, household cleaners, hair sprays, aerosol sprays, paint fumes, strong chemicals, or strong odors.

  • Cold air or weather changes. Cold air may cause inflammation. Winds increase molds and pollens in the air.

  • Strong emotions such as crying or laughing hard.

  • Stress.

  • Certain medicines such as aspirin or beta-blockers.

  • Sulfites in such foods and drinks as dried fruits and wine.

  • Infections or inflammatory conditions such as a flu, cold, or inflammation of the nasal membranes (rhinitis).

  • Gastroesophageal reflux disease (GERD). GERD is a condition where stomach acid backs up into your throat (esophagus).

  • Exercise or strenous activity.

WHEN WELL: ASTHMA UNDER CONTROL

ExitCare Image Symptoms: No cough or wheezing, chest tightness, or shortness of breath either during the day or at night; can participate in usual activities.

If using a peak flow meter:

My optimal peak flow is: _____ to _____ (should be 80–100% of personal best)

Medicines:

Every day:

  • Controller: ________________ How much? ________________ When? ________________

  • Controller: ________________ How much? ________________ When? ________________

Before exercise:

  • Reliever: ________________ How much? ________________ When? ________________

If symptoms are noted:

  • Reliever/Rescue: ________________ How much? ________________ When? ________________

Call your physician if using a reliever more than 2–3 times per week.

WHEN NOT WELL: ASTHMA GETTING WORSE

ExitCare Image Symptoms: Cough, wheeze, shortness of breath, chest tightness, waking at night due to asthma, unable to participate in all of usual activities.

If using a peak flow meter:

My peak flow is: _____ to _____ (50–79% of personal best)

Add the following medicine to those used daily:

  • Reliever/Rescue: ________________ How much? ________________ When? ________________

If symptoms and peak flow return to GREEN ZONE after 1 hour of above treatment, continue monitoring to make sure you remain in green zone.

If symptoms and peak flow DO NOT return to GREEN ZONE after 1 hour of above treatment:

  • Reliever/Rescue: ________________ How much? ________________ When? ________________

  • Oral Steroids: ________________ How much? ________________ When? ________________

  • Call your physician if: ______________________________________________________________

IF SYMPTOMS GET WORSE: ASTHMA IS SEVERE – GET HELP NOW!

Symptoms: Severely short of breath, rescue meds have not helped, cannot participate in usual activities, you are having trouble walking or talking due to asthma symptoms, you are dizzy or faint, your fingernails or lips are bluish, your symptoms are the same or worse after 24 hours in Yellow Caution Zone.ExitCare Image

If using a peak flow meter:

My peak flow is: less than _____ (50% of personal best)

Add the following medicine to those used daily:

  • Reliever/Rescue: ________________ How much? ________________ When? ________________

  • Oral Steroids: ________________ How much? ________________ When? ________________

  • CALL YOUR PHYSICIAN IMMEDIATELY.

If you are in the red danger zone and cannot reach your physician immediately, call your local emergency services (911 in U.S.) without delay. If emergency services are far away and will take a long time to get to you, have someone drive you directly to a hospital emergency department or meet emergency services en route to you.