My COPD Action Plan
Overview:
The My COPD Action Plan is a personalized guide to help you manage your Chronic Obstructive Pulmonary Disease (COPD). This plan is designed to assist you in recognizing daily activities, monitoring symptoms, and knowing when to take action to maintain your health.
Use this link to download a printable action plan document
Personal Information
- Name: ________________________________________
- Date: _________________
- Doctor’s Name: _________________________________
- Phone: ________________
- Emergency Contact: ________________________________
- Phone: ________________
Daily Activities Checklist
Use this checklist to assess your ability to perform daily activities. Evaluate your capabilities on a typical “green” day and note any activities you would like to be able to do again. Check the appropriate boxes and discuss your goals with your healthcare team and family.
| Activity | I can do this | I can do this w/minor limitations | I struggle to do this | I cannot do this | Desired Activity |
|---|---|---|---|---|---|
| Cleaning | ☐ | ☐ | ☐ | ☐ | ☐ |
| Making my bed | ☐ | ☐ | ☐ | ☐ | ☐ |
| Brushing my teeth | ☐ | ☐ | ☐ | ☐ | ☐ |
| Bathing/Showering | ☐ | ☐ | ☐ | ☐ | ☐ |
| Walking | ☐ | ☐ | ☐ | ☐ | ☐ |
| Climbing stairs | ☐ | ☐ | ☐ | ☐ | ☐ |
| Working | ☐ | ☐ | ☐ | ☐ | ☐ |
| Sleeping | ☐ | ☐ | ☐ | ☐ | ☐ |
| Exercising | ☐ | ☐ | ☐ | ☐ | ☐ |
| Cooking | ☐ | ☐ | ☐ | ☐ | ☐ |
Normal vs. Bad Days
A Normal Day for Me
- My breathing is normal
- My cough and mucus are normal
- My sleeping is normal
- My eating and appetite are normal
- My activity level is normal
A Bad Day for Me
- I have a low-grade fever that doesn’t go away
- I have increased use of rescue medications without relief
- I have a change in color, thickness, odor, or amount of mucus
- I am more tired than normal or have trouble sleeping
- I have new or more ankle swelling
- I am more breathless than normal
- I feel like I am catching a cold
Take Action
For Yellow Days (Caution)
- Medications: Take all medications as prescribed.
- Appointments: Keep routine doctor appointments.
- Oxygen Use: Use oxygen as prescribed.
- Lifestyle: Exercise and eat regularly.
- Avoidance: Avoid inhaled irritants and bad air days.
- Update: Update your COPD Action Plan every 6 months.
For Red Days (Emergency)
- Activity: Limit your activity and use pursed-lips breathing.
- Medications: Take regular medications as prescribed.
- Report Changes: Report these changes to your doctor today.
- Special Medications: Start special medications prearranged with your doctor:
- Emergency: If symptoms are not improved within one day after taking special medications, consult your doctor.
Emergency Actions
- Immediate Help: Call 911 if you experience:
- Disorientation, confusion, or slurring of speech
- A blue color around your lips or fingers
- Severe shortness of breath or chest pain
- Coughing up blood
- Special Medications: Start these special medications prearranged with your doctor:
Regular Updates
- Plan Review: My COPD Action Plan can be used daily and should be updated every 6 months.
- Next Update: ________________________
Note: The contents of My COPD Action Plan are for informational purposes only and are not intended to be a substitute for professional medical advice, diagnosis, or treatment.
Take Action Today. Breathe Better Tomorrow