The following list of symptoms is not comprehensive, and you may experience other symptoms. Symptoms Action Medications I am well today: Lifestyle tips: Continue taking: Usual activity Take all medications XXXX Usual amount of coughing Use oxygen as prescribed AAAAA Sleep well Continue breathing exercises BBB Good appetite Avoid smoky places CCCCCCCCCCC Limit salt DDDDDD Report any weight gain of more than 3 lbs in a day I do not feel well: What to do: Continue usual medications More breathless Call your care coordinator: More/colored mucus Jane Hands Start the following medications: Tired/not hungry Phone: Use inhaler every n hours 111-555-9876 Ankles swollen Take EEEEE Gained 3 or more lbs Use pursed lip breathing Emergency: Get help now: Severe shortness of breath Dr. Beaver Call your doctor immediately: Fever or shaking chills Phone: 111-555-3737 Confused, unsteady, drowsy Coughing up blood Call 911 if individual is unresponsive Tightness in chest at rest Provide this plan to responders and describe symptoms Gained more than 5 lbs Action Steps for COPD Symptoms Action Medications I am doing well today: Lifestyle tips: Continue taking: Usual activity and exercise Use oxygen as prescribed ______________________
The following list of symptoms is not comprehensive, and you may experience other symptoms. Symptoms Action Medications I am well today: Usual activity Usual amount of coughing Sleep well Good appetite Lifestyle tips: Take all medications Use oxygen as prescribed Continue breathing exercises Avoid smoky places Limit salt Report any weight gain of more than 3 lbs in a day Continue taking: XXXX AAAAA BBB CCCCCCCCCCC DDDDDD I do not feel well: More breathless More/colored mucus Tired/not hungry Ankles swollen Gained 3 or more lbs What to do: Call your care coordinator: Jane Hands Phone: 111-555-9876 Continue usual medications Start the following medications: Use inhaler every n hours Take EEEEE Use pursed lip breathing Emergency: Severe shortness of breath Fever or shaking chills Confused, unsteady, drowsy Coughing up blood Tightness in chest at rest Gained more than 5 lbs Get help now: Call your doctor immediately: Dr. Beaver Phone: 111-555-3737 Call 911 if individual is unresponsive Provide this plan to responders and describe symptoms Action Steps for COPD Symptoms Action Medications I am doing well today: Usual activity and exercise Lifestyle tips: Use oxygen as prescribed Continue taking: ______________________
4-Patient-Action-Plan-Template.docx