Sample Asthma Action Plan For Children 0-5 Years
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1
2SAMPLE ASTHMA ACTION PLAN
Name
Asthma Action Plan,
DOB
for Children 0–5 Years
Record #
Health Care Provider’s Name
Health Care Provider’s Phone Number
Completed by
Date
Long-Term Control Medicines
Other Instructions
How Much To Take
How Often
(Use every day to stay healthy)
(such as spacers/masks, nebulizers
_____ times per day
EVERY DAY
_____ times per day
EVERY DAY
_____ times per day
EVERY DAY
Quick-Relief Medicines
How Much To Take
How Often
Other Instructions
NOTE: If this medicine is needed often
Give ONLY as needed
( _____ per week), call physician
Child is WELL and has no asthma symptoms,
Prevent asthma symptoms every day
even during active play
• Give the above long-term control medicines every day
• Avoid things that make the child’s asthma worse
Avoid tobacco smoke, ask people to smoke outside
Child is NOT WELL and has asthma symptoms that
CAUTION: Take action by continuing to give regular asthma medicines
may incude:
every day AND:
• Coughing
Give
• Wheezing
(include dose and frequency)
• Runny nose or other cold symptoms
• Breathing harder or faster
If the Child is not in the Green Zone and still has symptoms after 1 hour:
• Awakening due to coughing or difficulty breating
Give
• Playing less than usual
•
(include dose and frequency)
•
Give
Other symptoms that could indicate that your child is having
(include dose and frequency)
trouble breathing may include: difficulty feeding (grunting
sounds, poor sucking), changes in sleep patterns, cranky and
Call
tired, decreased appetite
MEDICAL ALERT! Get help!
Child FEELS AWFUL warning signs may incude:
• Child’s wheeze, cough or difficult breathing continues
Take the child to the hospital or call 9-1-1 immediately!
or worsens, even after giving yellow zone medicines
G ive more
• Child’s breathing is so hard that he/she is having
(include dose and frequency) until you get help
trouble walking/talking/eating/playing
G ive more
• Child is drowsy or less alert than normal
DANGER!
(include dose and frequency) until you get help
Get help immediately! Call 9-1-1 if:
• The child’s skin is sucked in around neck and ribs or
• Lips and/or fingernails are grey or blue, or
• Child doesn't respond to you.
Source: San Francisco Bay Area Regional Asthma Management Plan.
Source: National Heart, Lung, and Blood Institute National Asthma Education and Prevention. Expert Panel Report 3; Guidelines for the Diagnosis
and Management of Asthma; Full Report 2007. Bethesda, MD: NHLBI; 2007:118.
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