MY COPD 
ACTION PLAN 	
Your doctor, nurse and other members of your healthcare team can help you fill in your COPD action plan. Review it each year, and also after a flare-up. 	
MY DETAILS	MY HEALTHCARE TEAM	
Name: <<Patient Demographics:Full Name>>	Doctor: <<Doctor:Name>>	
Date of Birth: <<Patient Demographics:DOB>>	Phone: <<Practice:Phone>>	
Date of influenza Immunisation (annual):	 Date of pneumococcal immunisation: 	
<<Date of Influenza Immunisation?>>	<<Date of pneumococcal Immunisation?>>	
Other members of your healthcare team:	If I am unwell, I can call who on for after hours advice. 
<<If I am unwell who I can call for after hours advice?>>	
<<Name & Profession of other Healthcare Team?>>		

I have a usual amount of phlegm/breathlessness. I can do my usual activities. 	

ACTION: Take your usual COPD medicines.

My FEV is: <<My FEV is? >>                  I retain CO2:   <<I retain CO2  >>

Medicine	Inhaler Colour	Number of puffs	Times per day	

				

I need to use home oxygen on <<I need to use home oxygen on  ???   setting >>   setting or L/min for <<or L/min for ?????   hours/day>>  Hours / day.

I am coughing more. I have more phlegm. It is harder to breathe than normal. 	
(Enter details below)
Action: Take your flare up medicines. Monitor your COPD symptoms closely. Call your doctor. 
Take _________ puffs of ___________ (reliever)__________ times every ________ hours / A.M. / P.M. (delete irrelevant one)

I have taken my extra medicines but I am not getting better.	
 
Take action now to manage your symptoms. Call your doctor. 

Shortness of breath or wheeze	Phlegm had changed colour or fever	
(Enter details below)
Action: Take _____ prednisolone tablets
1mg, 5mg or 25mg (delete irrelevant dosages) times per day for _______ days.   	(Enter details below)
Action: Take______ antibiotic tablets _____ times per day for _____ days. Antibiotic name: ___________	

       My COPD symptoms have changed a lot. I am worried. 	

Difficulty sleeping/woken easily
Blood in phlegm or swollen ankles	Very short of breath/wheezy
High fever or confusion
Chest pain or slurred speech	
ACTION: Call your healthcare team TODAY.	Action: CALL 000 NOW	
CAUTION:Ambulance / Parademics: Oxygen supplementation to maintain SpO2 88 - 92% to reduce risk of hypercapnia	

Health Professional authorisation 
This COPD Action Plan was prepared on <<Miscellaneous:Date (short)>> by <<Doctor:Name>> in consultation with the patient. 
Signature: <<Doctor:Name>>
Profession: <<Doctor:Qualifications>>
Entered into recall system:   <<Patient entered into recall system?>>

Get to know your baseline
Your baseline is when you feel your usual self. You may have one or more symptoms at your baseline. Think about: 
* How breathless you feel at rest  * Your usual amount of phlegm  * The colour of phlegm  * How well you sleep * How far you can walk. 	
Know your COPD medicines and inhalers
Your COPD medicines help control your symptoms, such as breathlessness, and reduce the risk of flare-ups. Take your COPD medicines as prescribed by your doctor. Use your inhaler device correctly to get the most benefit from your medicine. 	
You can reduce the risk of flare up 
COPD flare ups are serious health events. There are things you can to do reduce the risk of flare-up including: 
* Quit smoking  * Exercise daily * Join a pulmonary rehabilitation program  * Get influenza and pneumonia immunisations * Take your COPD medicines daily, as prescribed by your Doctor. 	
Learn how to use your inhaler device by watching our helpful videos.
1. Download ZAPPAR from Google Play or iTunes app store.
2. Open the app
3. Choose the inhaler device video. 	

My Local Support 	
Pulmonary rehabilitation program:		
Lungs in Action: 		
Support Group: 		

       Lung Foundation Australia       
www.lungfoundation.com.au
Ph: 1300 654 301