Asthma Treatment Plan Patient/Parent Instructions
The PACNJ Asthma Treatment Plan is designed to help everyone understand the steps necessary for the individual patient to achieve the goal of controlled asthma. 1. Patients/Parents/Guardians: Before taking this form to your Health Care Provider:
• Parent/Guardian’s name & phone number
• An Emergency Contact person’s name & phone number
• Patient’s doctor’s name & phone number
2. Your Health Care Provider will:
• The effective date of this plan • The medicine information for the Healthy, Caution and Emergency sections • Your Health Care Provider will check the box next to the medication and check how much and how often to take it • Your Health Care Provider may check “OTHER” and:
❖ Write in asthma medications not listed on the form ❖ Write in additional medications that will control your asthma ❖ Write in generic medications in place of the name brand on the form
• Together you and your Health Care Provider will decide what asthma treatment is best for you or your child to follow. 3. Patients/Parents/Guardians & Health Care Providers together:
Discuss and then complete the following areas:
• Patient’s peak flow range in the Healthy, Caution and Emergency sections on the left side of the form• Patient’s asthma triggers on the right side of the form• For Minors Only section at the bottom of the form: Discuss your child’s ability to self-administer the inhaled medications,
check the appropriate box, and then both you and your Health Care Provider must sign and date the form
4. Parents/Guardians: After completing the form with your Health Care Provider:
• Make copies of the Asthma Treatment Plan and give the signed original to your child’s school nurse or child care provider• Keep a copy easily available at home to help manage your child’s asthma• Give copies of the Asthma Treatment Plan to everyone who provides care for your child, for example: babysitters,
before/after school program staff, coaches, scout leaders
This Asthma Treatment Plan is meant to assist, not replace, the clinical decision-making required to meet individual patient needs. Not all asthma medications are listed and the generic names are not listed. Disclaimers: The use of this Website/PACNJ Asthma Treatment Plan and its content is at your own risk. The content is provided on an “as is” basis. The American Lung Association of the Mid-Atlantic (ALAM-A), the Pediatric/Adult Asthma Coalition of New Jersey and all affiliates disclaim all warranties, express or implied, statutory or otherwise, including but not limited to the implied warranties or merchantability, non-infringement of third parties’ rights, and fitness for a particular purpose.
ALAM-A makes no representations or warranties about the accuracy, reliability, completeness, currency, or timeliness of the content. ALAM-A makes no warranty, representationor guaranty that the information will be uninterrupted or error free or that any defects can be corrected.
In no event shall ALAM-A be liable for any damages (including, without limitation, incidental and consequential damages, personal injury/wrongful death, lost profits, or damagesresulting from data or business interruption) resulting from the use or inability to use the content of this Asthma Treatment Plan whether based on warranty, contract, tort or anyother legal theory, and whether or not ALAM-A is advised of the possibility of such damages. ALAM-A and its affiliates are not liable for any claim, whatsoever, caused by youruse or misuse of the Asthma Treatment Plan, nor of this website.
The Pediatric/Adult Asthma Coalition of New Jersey, sponsored by the American Lung Association of New Jersey, and this publication are supported by a grant from the New Jersey Department of Health andSenior Services (NJDHSS), with funds provided by the U.S. Centers for Disease Control and Prevention (USCDCP) under Cooperative Agreement 5U59EH000206-3. Its contents are solely the responsibility ofthe authors and do not necessarily represent the official views of the NJDHSS or the USCDCP. Although this document has been funded wholly or in part by the United States Environmental Protection Agencyunder Agreement XA97256707-2 to the American Lung Association of New Jersey, it has not gone through the Agency’s publications review process and therefore, may not necessarily reflect the views of theAgency and no official endorsement should be inferred. Information in this publication is not intended to diagnose health problems or take the place of medical advice. For asthma or any medical condition,seek medical advice from your child’s or your health care professional.
(This asthma action plan meets NJ Law N.J.S.A. 18A:40-12.8) (Physician’s Orders)
➠ Takedailymedicine(s).Somemetereddoseinhalersmay be more effective with a “spacer” – use if directed You have all of these: Triggers MEDICINE HOW MUCH to take and HOW OFTEN to take it Check all items
Advair ® Ⅺ 100, Ⅺ 250, Ⅺ 500 __________1 inhalation twice a day
Ⅺ Advair® HFA Ⅺ 45, Ⅺ 115, Ⅺ 230________2 puffs MDI twice a day
Ⅺ Alvesco® Ⅺ 80, Ⅺ 160 __________________Ⅺ 1, Ⅺ 2 puffs MDI twice a day
Ⅺ Asmanex® Twisthaler® Ⅺ 110, Ⅺ 220 ______Ⅺ 1, Ⅺ 2 inhalations Ⅺ once or Ⅺ twice a day
Ⅺ Flovent® Ⅺ 44, Ⅺ 110, Ⅺ 220___________2 puffs MDI twice a day
Ⅺ Flovent® Diskus® Ⅺ 50 Ⅺ 100 Ⅺ 250 _____1 inhalation twice a day
Pulmicort Flexhaler® Ⅺ 90, Ⅺ 180________Ⅺ 1, Ⅺ 2 inhalations Ⅺ once or Ⅺ twice a day
Pulmicort Respules® Ⅺ 0.25, Ⅺ 0.5, Ⅺ 1.0 __1 unit nebulized Ⅺ once or Ⅺ twice a day
Qvar ® Ⅺ 40, Ⅺ 80 ____________________Ⅺ 1, Ⅺ 2 puffs MDI twice a day
Ⅺ Singulair Ⅺ 4, Ⅺ 5, Ⅺ 10 mg____________1 tablet daily
Ⅺ Symbicort® Ⅺ 80, Ⅺ 160_______________Ⅺ 1, Ⅺ 2 puffs MDI twice a day
Remember to rinse your mouth after taking inhaled medicine. If exercise triggers your asthma, take this medicine_____________________ ____ minutes before exercise.
➠ Continuedailymedicine(s)andaddfast-actingmedicine(s). ❏Plants,flowers, You have any of these: MEDICINE HOW MUCH to take and HOW OFTEN to take it
Accuneb® Ⅺ 0.63, Ⅺ 1.25 mg _________1 unit nebulized every 4 hours as needed
Ⅺ Albuterol Ⅺ 1.25, Ⅺ 2.5 mg ___________1 unit nebulized every 4 hours as needed
Ⅺ Albuterol Ⅺ Pro-Air Ⅺ Proventil® _______2 puffs MDI every 4 hours as needed
Ⅺ Ventolin® Ⅺ Maxair Ⅺ Xopenex® _______2 puffs MDI every 4 hours as needed
Ⅺ Xopenex® Ⅺ 0.31, Ⅺ 0.63, Ⅺ 1.25 mg __1 unit nebulized every 4 hours as needed
Ⅺ Other ➡ Iffast-actingmedicineisneededmorethan2timesaweek, except before exercise, then call your doctor. EMERGENCY ➠ Take these medicines NOW and call 911. Your asthma is getting worse fast: Asthma can be a life-threatening illness. Do not wait!
• Fast-acting medicine did not Ⅺ Accuneb® Ⅺ 0.63, Ⅺ 1.25 mg _________1 unit nebulized every 20 minutes
Ⅺ Albuterol Ⅺ 1.25, Ⅺ 2.5 mg ___________1 unit nebulized every 20 minutes
Ⅺ Albuterol Ⅺ Pro-Air Ⅺ Proventil® _______2 puffs MDI every 20 minutes
Ⅺ Ventolin® Ⅺ Maxair Ⅺ Xopenex® _______2 puffs MDI every 20 minutes
Ⅺ Xopenex® Ⅺ 0.31, Ⅺ 0.63, Ⅺ 1.25 mg __1 unit nebulized every 20 minutes
The Pediatric/Adult Asthma Coalition of New Jersey, sponsored by the AmericanLung Association of New Jersey, and this publication are supported by a grantfrom the New Jersey Department of Health and Senior Services (NJDHSS), with
FOR MINORS ONLY:
funds provided by the U.S. Centers for Disease Control and Prevention (USCDCP)
PHYSICIAN/APN/PA SIGNATURE______________________________ DATE__________
under Cooperative Agreement 5U59EH000206-3. Its contents are solely the re-sponsibility of the authors and do not necessarily represent the official views of
Ⅺ This student is capable and has been instructed in the
Although this document has been funded wholly or in part by the
proper method of self-administering of the non-nebulized
United States Environmental Protection Agency under AgreementXA97256707-2 to the American Lung Association of New Jersey, it has
inhaled medications named above in accordance with
not gone through the Agency’s publications review process and there-fore, may not necessarily reflect the views of the Agency and no official
Ⅺ This student is not approved to self-medicate.
Permission to reproduce blank formwww.pacnj.org
Make a copy for patient and for physician file. For children under 18, send original to school nurse or child care provider.
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