Your Home Medications |
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Name of Medication (Unit dose) |
How Much |
How Many Times a Day |
Quick-Relief Medicine
(to be taken only to stop asthma symptoms) |
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Long-Term
Control Medicine
(to be taken every day) |
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Type of inhaled medicine or Spacer for inhaler |
[ ] MDI inhaler [ ] Diskus [ ] Autohaler
[ ] Aerochamber [ ] Aerochamber with mask [ ] Nebulizer |
Pediatric Asthma Action Plan |
GREEN ZONE
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-No symptoms of asthma
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Continue all Long-Term Control Medicine everyday as instructed.
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YELLOW ZONE
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-Coughing,
-Wheezing,
-Chest tightness, or
-Shortness of breath,
-Waking up at night due to asthma symptoms.
-Some of the usual activities are limited |
1. Continue your daily Long-Term Control Medicine.
2. Immediately take your Quick-Relief Medicine every 20 minutes up to 3 times.
3. Continue to take your quick relief medicine every 4-6 hours until all asthma symptoms clear.
4. Call your doctor if your asthma symptoms do not clear after 1 hour of using the Quick-Relief Medicine.
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RED ZONE
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-Very short of breath.
-Breathing fast and hard.
-Usual activities severely limited.
-Difficulty feeding.
-Symptoms are the same or worse after 24 hours in the Yellow Zone
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1. Take your Quick-Relief medicine right away.
2. Give Prednisone right away if you have it.
3. Call your doctor or go to the nearest clinic or emergency room. |
Verbal and Written Instructions Given
(Check all that apply) |
[ ] What is Asthma [ ] Proper use of Asthma medicine
[ ] How to take inhaled medicine [ ] Exercise and asthma
[ ] Environmental Control at home [ ] Avoid asthma triggers
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What brings on your asthma symptoms? |
[ ] Weather change; [ ] Cold air; [ ] Catching a cold; [ ] Crying or when upset
[ ] Dust; [ ] Smoke; [ ] Running or playing hard; [ ] Out of medicine
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Follow-up appointment |
Name of doctor [ ] Date [ / / ] ; Time [ ]
UIC Pediatic Clinic (1801 W. Taylor Street. Chicago, IL 60612) TEL:312-996-7614 |
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