NORTH DAKOTA ASTHMA ACTION PLAN NORTH DAKOTA DEPARTMENT OF HEALTH DIVISION OF CHRONIC DISEASE SFN 59187 (11-2009)

The colors of a traffic light will help you use your asthma medicines: Red: Danger Zone! Get help from a doctor

Name

Date

Parent/Guardian(s) Name(s)

Telephone Number

Emergency Contact

Telephone Number

Yellow: Caution Zone! Add quick-relief medicine

Prescribing Health-Care Provider

Telephone Number

Green: Go Zone! Use controller medicine

Health-Care Provider's Signature

Peak Flow Personal Best

Emergency Medication Possession and Self-Administration Approval Student has received instruction in self-administration of emergency medication. (Initial)

Date Approval Expires

List Rescue Medicine (follow the action plan for proper use)

GO!

Use these anti-inflammatory/controller medicines every day: MEDICINE

l No cough or wheeze l Breathing is good

For asthma with exercise, take: Rescue Medicine

l Sleep through the night CAUTION:

Continue with green zone medicine and add: MEDICINE

l First signs of a cold

HOW MUCH

HOW OFTEN

Rescue Medicine Did symptoms improve or peak flow return to green zone?

l Exposure to a known trigger

l Mild wheeze

HOW OFTEN

Peak Flow Reading Above

l Can work and play

l Cough day or night

HOW MUCH

Peak Flow Reading to

iNO gYES Have you been in the yellow zone for more than 24 hours? iNO gYES MEDICINE

HOW MUCH

Return to green zone medications and follow peak flows Call your Health-Care Provider

HOW OFTEN

Rescue Medicine

l Tight Chest l DANGER!

Take these rescue medicines and call your health-care provider now ! MEDICINE

l Breathing is hard and fast l Nose opens wide / ribs show l Medicine isn't working l Can't talk well l

Peak Flow Reading Below

HOW MUCH

HOW OFTEN

Rescue Medicine

GET HELP FROM A HEALTH PROVIDER NOW! It's important! If you cannot contact your provider, call 911 or go directly to the emergency room. DO NOT WAIT! Form available at: http://www.ndhealth.gov/asthma/forms.htm

Asthma Action Plan-Dr. form.pdf

Call your Health-Care Provider ... NORTH DAKOTA DEPARTMENT OF HEALTH ... Emergency Medication Possession and Self-Administration Approval.

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