Asthma Action Plan Template for Preschool Children

ADVERTISEMENT
A
A
P
20__ - 20__
STHMA
CTION
LAN F OR PRESCHOOL CHILDREN YEAR
Name
DOB
____________________________________________________
_________________________________
Parent/Guardian
________________________________________________________________________________
Ph (Home)
Ph (Cell)
________________________________________________
_____________________________
Doctor
Ph
M
M
S
E
C
-
ATEGORY
OF SEVERITY
ILD
ODERATE
EVERE
XERCISE
INDUCED ASTHMA
Use Controller Medicines at Home Every Day
GO
MEDICINE/ROUTE
HOW MUCH
HOW OFTEN/WHEN
Child is feeling well

Breathing is good

No cough or wheeze

Sleeps through the night

Can play
CAUTION
Rescue Medicine
MEDICINE/ROUTE
HOW MUCH
HOW OFTEN/WHEN
Child is not feeling well

COUGHING day or night
 Give a
Stay with child and keep child
Rescue medicine:

Wheezing–hard or noisy
nebulizer
quiet for 15 minutes
breathing
_____________________
treatment

Vomiting after coughing
Encourage child to drink fluids
Other symptoms
If symptoms not improved, may

Trouble breathing
repeat rescue medicine ONCE
Give ____
 Nebulizer
 Mask

Trouble eating
puffs of
Call parent to report child had

Cranky and tired
metered
 Spacer
 Inhaler
breathing problem
dose inhaler
Other Signs
IF STILL HAVING

Change in sleep pattern
TROUBLE,

Not playing as usual
FOLLOW RED ZONE

Reaction to asthma trigger
NOTE: Parent should contact the doctor if child needs rescue med >2 times/wk to see if a medication change is necessary.
STOP
Get Help from a Doctor
MEDICINE/ROUTE
HOW MUCH
HOW OFTEN/WHEN
Child is very sick
Give a
Rescue medicine:
Give rescue medicine NOW
Danger-Get Help!
nebulizer
_____________________
treatment
Watch child closely

Medicine is not helping
Repeat rescue medicine in
Give______

 Nebulizer
 Mask
Constant cough
15 minutes if still in distress
puffs of

Working hard to breathe
 Spacer
 Inhaler
metered dose

Trouble walking or talking
inhaler

Child looks very sick
Call parent. If not better, call doctor.
IF IN SEVERE DISTRESS, CALL 911.
Doctor signature:
Date
I hereby release the local School Board and their agents and employees and the child care providers from any liability that may result from my
child taking the prescribed medication. I give permission for my child to receive medications and for health care providers to exchange
information regarding the care of my child. I agree to provide rescue medication to be kept at the child care center in case of emergency.
Parent/Guardian:
Date
/
WHITE
CHILD CARE PROVIDER
YELLOW
PATIENT
PARENT
PINK
DOCTOR
Albemarle Pediatric Asthma Coalition
O
03/08
06/09
RIGINAL
REV
A
A
P
20__ - 20__
STHMA
CTION
LAN F OR PRESCHOOL CHILDREN YEAR
Name
DOB
____________________________________________________
_________________________________
Parent/Guardian
________________________________________________________________________________
Ph (Home)
Ph (Cell)
________________________________________________
_____________________________
Doctor
Ph
M
M
S
E
C
-
ATEGORY
OF SEVERITY
ILD
ODERATE
EVERE
XERCISE
INDUCED ASTHMA
Use Controller Medicines at Home Every Day
GO
MEDICINE/ROUTE
HOW MUCH
HOW OFTEN/WHEN
Child is feeling well

Breathing is good

No cough or wheeze

Sleeps through the night

Can play
CAUTION
Rescue Medicine
MEDICINE/ROUTE
HOW MUCH
HOW OFTEN/WHEN
Child is not feeling well

COUGHING day or night
 Give a
Stay with child and keep child
Rescue medicine:

Wheezing–hard or noisy
nebulizer
quiet for 15 minutes
breathing
_____________________
treatment

Vomiting after coughing
Encourage child to drink fluids
Other symptoms
If symptoms not improved, may

Trouble breathing
repeat rescue medicine ONCE
Give ____
 Nebulizer
 Mask

Trouble eating
puffs of
Call parent to report child had

Cranky and tired
metered
 Spacer
 Inhaler
breathing problem
dose inhaler
Other Signs
IF STILL HAVING

Change in sleep pattern
TROUBLE,

Not playing as usual
FOLLOW RED ZONE

Reaction to asthma trigger
NOTE: Parent should contact the doctor if child needs rescue med >2 times/wk to see if a medication change is necessary.
STOP
Get Help from a Doctor
MEDICINE/ROUTE
HOW MUCH
HOW OFTEN/WHEN
Child is very sick
Give a
Rescue medicine:
Give rescue medicine NOW
Danger-Get Help!
nebulizer
_____________________
treatment
Watch child closely

Medicine is not helping
Repeat rescue medicine in
Give______

 Nebulizer
 Mask
Constant cough
15 minutes if still in distress
puffs of

Working hard to breathe
 Spacer
 Inhaler
metered dose

Trouble walking or talking
inhaler

Child looks very sick
Call parent. If not better, call doctor.
IF IN SEVERE DISTRESS, CALL 911.
Doctor signature:
Date
I hereby release the local School Board and their agents and employees and the child care providers from any liability that may result from my
child taking the prescribed medication. I give permission for my child to receive medications and for health care providers to exchange
information regarding the care of my child. I agree to provide rescue medication to be kept at the child care center in case of emergency.
Parent/Guardian:
Date
/
WHITE
CHILD CARE PROVIDER
YELLOW
PATIENT
PARENT
PINK
DOCTOR
Albemarle Pediatric Asthma Coalition
O
03/08
06/09
RIGINAL
REV

Download Asthma Action Plan Template for Preschool Children

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