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SAMPLE ASTHMA ACTION PLAN
Asthma Action Plan,
for Children 0–5 Years
Health Care Provider’s Name
Health Care Provider’s Phone Number Completed by Date
Long-Term Control Medicines
(Use every day to stay healthy) How Much To Take How Often
Other Instructions
(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
Give ONLY as needed
NOTE: If this medicine is needed often
( _____ per week), call physician
GREEN ZONE
Child is WELL and has no asthma symptoms,
even during active play
Prevent asthma symptoms every day
• 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
YELLOW ZONE
Child is NOT WELL and has asthma symptoms that
may incude:
• Coughing
• Wheezing
• Runny nose or other cold symptoms
• Breathing harder or faster
• Awakening due to coughing or difficulty breating
• Playing less than usual
•
•
Other symptoms that could indicate that your child is having
trouble breathing may include: difficulty feeding (grunting
sounds, poor sucking), changes in sleep patterns, cranky and
tired, decreased appetite
CAUTION: Take action by continuing to give regular asthma medicines
every day AND:
Give
(include dose and frequency)
If the Child is not in the Green Zone and still has symptoms after 1 hour:
Give
(include dose and frequency)
Give
(include dose and frequency)
Call
RED ZONE
Child FEELS AWFUL warning signs may incude:
• Child’s wheeze, cough or difficult breathing continues
or worsens, even after giving yellow zone medicines
• Child’s breathing is so hard that he/she is having
trouble walking/talking/eating/playing
• Child is drowsy or less alert than normal
DANGER!
MEDICAL ALERT! Get help!
Take the child to the hospital or call 9-1-1 immediately!
Give more
(include dose and frequency) until you get help
Give more
(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.
Name
DOB
Record #
Source: http://www.calasthma.org/uploads/resources/actionplanpdf.pdf. San Francisco Bay Area Regional Asthma Management Plan.
http://www.rampasthma.org
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.