Asthma Action Plan

Student’s Name: Date of Birth: Date of Plan:

Usual Daily Medications:

Usual “Best” Peak Flow:

Yellow Zone: If the child has difficulty breathing, wheezing, or peak flow is under :

Give Albuterol MDI (2 puffs or nebulizer), then recheck Peak Flow in 10 minutes.

· If Peak Flow improves and the child is breathing normally:

o the child may return to class.

o Recheck Peak Flow in 4 hours and notify parent.

· If Peak Flow has not improved in 10 minutes, notify parent or our office.

Red Zone: If the Peak Flow is under or the child is in distress:

· Give Albuterol MDI 2 puffs or nebulizer.

· Call parent, our office, or 911 immediately.

q This child has been instructed in the proper way to use his/her medications. In my professional opinion, he/she should be allowed to carry and use the medications by him/herself.

q This child should receive his medications from the school nurse as needed.

Asthma Action Plan

Physician Date

Parent Date