LalliCareClinic.ca

1139 Yates St - Victoria , BC V8V 3N2 - PHONE: 250-386-5100 - Fax: 250-386-5527 - TOLL FREE: 1-866-261-4165

Asthma - Your Personal Action Plan


Print out this action plan (PDF page 1, PDF page 2and use to monitor you asthma. Bring it with you to your doctor appointments -- this information will be very useful in assisting him/her to assess your condition.             

 

Date : ______

 

My Personal Best Peak Flow __________

 

Doing Well

Symptoms

·          No/minimal/few symptoms such as cough, wheeze, chest tightness or shortness of breath.

·          No limitations in usual activities.

·          My usual medicines control my asthma.

 

Green Zone

 

Peak flow: _____to_____

(80-100% of my personal best peak flow.)

When I am doing well, I should follow my daily treatment plan:

Medicine

Dose

Maximum  number of times/day and duration

 

Reliever:

Preventer :

Other :

 

 

 

 

 

 

 

Caution

Symptoms

·          Presence or increase of such symptoms as cough, wheeze, chest tightness or shortness of breath (including symptoms at night.)

·          Limitations in your ability to perform usual activities.

·          Increased need for asthma (reliever) medicine

 

Yellow Zone

 

Peak flow: _____to_____

(50-80% of my personal best peak flow.)

When I am in the caution/yellow zone, I should adjust my current medicines and/or add medicines as indicated below:

Medicine

Dose

Maximum  number of times/day and duration

 

Reliever:

Preventer :

Other :

 

 

 

 

 

 

 

Caution

Symptoms

·          Extreme cough, wheeze, chest tightness or shortness of breath (including symptoms at night.)

·          Cannot perform usual activities.

·          Symptoms are the same or worse after 24 hours in the CAUTION/Yellow zone.

·          Asthma medicines have not reduced symptoms.

 

Yellow Zone

 

Peak flow: _____to_____

(Less than 50% of my personal best peak flow.)

When I am in the medical alert/red zone, I should  adjust my current medicines and/or add medicines as indicated below:

Medicine

Dose

Maximum  number of times/day and duration

 

Reliever:

Preventer :

Other :

 

 

 

 

 

 

 

 

I should call the doctor immediately when :

·          My reliever medicine is not helping my symptoms as well as it should.

  • My shortness of breath is getting worse even when I am   using my medicines properly.

I need to go to the hospital now or call 911 now if :

·          My reliever drug is not working.

·          I suddenly feel faint or frightened.

·          I have difficulty talking due to shortness of breath.

·          My lips or fingernails are blue.

·          A  child with asthma is having a hard time breathing and is hunched over and/or struggling to breathe.

WHEN IN DOUBT, GO TO THE HOSPITAL.




Emergency Telephone Numbers:

 

Emergency Help Line: 911 or other ____________

Nearest Emergency Room: ____________

Ambulance: ____________

My Doctor: ____________

 

© Copyright RealWeb Enterprises Ltd.
all rights reserved