Child Asthma Action Plan For Ages 0 To 5 Years Of Age
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1
2If your child f
If your child still does not feel w
Patient Name:
____________________________________________
DOB: ___________________________________________________
Child Asthma Action Plan
Healthcare Provider’s Name: ________________________________
Ages 0–5 Years Old:
Review and update at each Doctor’s visit
Healthcare Provider’s Phone #: ______________________________
Child is Well
PREVENT asthma symptoms everyday:
Avoid things that make your child’s asthma worse
…and has no asthma symptoms,
Give your child the controller medicines everyday:
even during play
MEDICINE
HOW MUCH
WHEN
Optional Instructions:
At the onset of respiratory illness,
Give
times a day for
days
ICS
Child is Not Well
CAUTION, asthma symptoms are present
Give
2
4 puffs
nebulizer,
…and has asthma symptoms that may include:
RESCUE MEDICINE
every 20 minutes for up to 1 hour, as needed
• Coughing
If y
If your child f
our child feels better
eels better and is back in the Green Zone continue
eels better and is back in the Green Zone continue
and is back in the Green Zone continue
and is back in the Green Zone continue
• Wheezing
the Green Zone medicines
• Runny nose or other cold symptoms
If symptoms persist give
• Breathing harder or faster
RESCUE MEDICINE
2
4 puffs
nebulizer, every
hours
• Waking due to coughing
or difficulty breathing
If y
If your child still does not f
our child still does not feel w
eel well ell and he/she continues to need
ell and he/she continues to need
and he/she continues to need
and he/she continues to need
• Playing less than usual
rescue medicine for more than
hours, call your doctor and have
your child take the following medicines:
Other symptoms that could indicate
that your child is having difficulty
Give
times a day for
days
breathing may include: difficulty
ICS
feeding (grunting sounds, poor
Give
time(s) a day for
days
sucking), changes in sleep patterns,
ORAL STEROID
cranky and tired, decreased appetite
Continue all other Green Zone medicines
If your child’s symptoms worsen call your doctor
Child Feels Awful!
DANGER! Get help immediately!
Give
Warning signs may include:
RESCUE MEDICINE
2
4 puffs
nebulizer, every 20 minutes
• Child’s wheeze, cough or difficulty breathing continues
or worsens, even after giving Yellow Zone medications
Call your Doctor’s office now.
If you can’t reach them, go to the hospital Ê
• Child’s breathing is so
hard that he/she is having
trouble walking/talking/
eating/playing or child
is drowsy or less alert
Call 911 if your child has trouble walking or talking
than normal
due to shortness of breath or lips/fingernails are
grey or blue Ê
Completed by:
Date:
AUTHORIZATION AND DISCLAIMER FROM PARENT/GUARDIAN: MY CHILD
MAY CARRY AND SELF-ADMINISTER ASTHMA MEDICATIONS
YES
NO AND
I AGREE TO RELEASE THE SCHOOL DISTRICT AND SCHOOL PERSONNEL FROM
ALL CLAIMS OF LIABILITY IF MY CHILD SUFFERS ANY ADVERSE REACTIONS
Parent Signature:
Date:
FROM SELF-ADMINISTRATION OF ASTHMA MEDICATIONS.
PHYSICIAN: MY SIGNATURE PROVIDES AUTHORIZATION FOR THE ABOVE
WRITTEN ORDERS. STUDENT MAY CARRY AND SELF-ADMINISTER ASTHMA
Physician Signature:
Date:
MEDICATIONS
YES
NO.
FOR MORE INFORMATION ON CHILDHOOD ASTHMA VISIT OUR WEBSITE AT:
TOP SHEET: PATIENT
SECOND SHEET: CHILD CARE/SCHOOL/OTHER SUPPORT SYSTEM
LAST SHEET: MEDICAL RECORD
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