Did I do something wrong?

Specialties School

Published

Let me apologize in advance for the long post, but I feel the whole story is necessary. I am new to school nursing started in February for a 3-4 grade school. I am dealing with an angry parent situation and I am not sure what, if anything, that I did wrong. One of my students with asthma came to me in March with a note from mom saying she had bronchitis. At this time, she did not use any daily inhalers or asthma meds at school but she has two PRN inhalers on campus. There was an attached pediatrician's note ordering she use her Xopenex inhaler before PE for the following 3 weeks or until the bronchitis has resolved. Ok, check the students medical file, she has a parent permission slip for Xopenex prn and Azmacort once daily only if home dose has been missed. Fine, so we will do the Xopenex for 3 weeks. At the end of this period I call the parent letting her know that I would like a doctor's note saying that the bronchitis is sufficiently resolved before I feel comfortable discontinuing the Xopenex. Mom says she hasn't had a chance to take her to the doctor, so just continue the Xopenex before PE and she will take her as soon as possible. This was March, and despite calling again and asking for a note, the student was never returned to her pediatrican for follow up. So we are still doing the Xopenex before PE. During these past few months, seeing the student on a daily basis, I have observed her using her inhaler properly (she is 10) and she has never had any c/o SOB or acute attacks at school. This student comes to me Thursday morning 8:30 am complaining of "I don't feel good". She was more quiet than usual, but couldn't tell me anything specific that was bothering her. Vital signs look good, no fever, no red throat, no respiratory complaints. I let her rest for a period of about 30 minutes and then attempt to return to class. She tells me that she didn't feel well last night and her mom says she had a fever. Ok, so I am calling mom. Mom confirms, but says also no specific complaints last night and fever was low grade less than 100. She says to me "I don't even know if I brought one, but does she have a peak flow meter there? She sometimes gets this way when her asthma acts up". I respond, "I can't reach that cabinet right now but I will look in one minute. Why don't I check her oxygen level while I have you on the phone." Check the O2 sat 100%, pulse in the 80's, lungs clear, no c/o SOB. Student sitting in chair doodling on some paper. I tell mom the results and she says, "Ok, she is fine then. But I am going to send her dad to get her anyway since she isn't feeling well.". Whatever, you are the parent, your kid, your call. An hour and a half later dad shows up to get her.....she is in the clinic with me this whole waiting period, reading, talking with other students who come in, ect. Obviously not distressed. Mom leaves message for Asst. Prinicpal Friday morning saying that student had asthma attack Thursday night and they were at ER all night. She also expresses concern that her daughter's asthma is not being properly taken care of at school.....that she asked me several times to do a peak flow (no, just one time) and that we are not using the child's spacer for her inhaler. The part about the spacer is correct. I have seen the student use her inhaler properly, and assumed, maybe wrongly that the spacer was only for the Azmacort, as I know it can help lesson thrush, ect. that can be caused by the steroid inhalers. The student never expressed to me that she needed to use the spacer and I was under the assumption if the student can use the MDI properly they do not need to use the spacer. The parent did not return her asthma care plan given at registration, which details any daily orders for asthma and emergency plan. All that I found in her file was the above mentioned orders for the inhalers. Even if it were returned, I wouldn't have followed it Thursday as she was obviously not having an asthma attack. My opinion is if you were concerned about your child's asthma Wednesday night, why did you send her to school Thursday and then take an hour and a half to pick her up? And what does an asthma attack 12 hours later have to do with an obviously undistressed child with a O2 sat of 100% in the nurse's clinic that morning? Should I have done something different? Opinions are requested. Anyone that actually read all of this, thank you!

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Specializes in med surg, geriatrics, peds.

It seems to me that you did what you were supposed to. My son is 10 and has asthma and we do not always use peak flow. She may have been coming down with something but ther was no way to know that. All you can go on is objective data and you went with subjective by calling mom when child said she didn't feel well.

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Specializes in Coronary Care, School Nurse.

I think you did fine. I wonder what her peak flow was at home. Did they have her check it then? Flare ups can happen quickly. Make sure you document everything!

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Specializes in School Nursing.

I think you did fine, too. I have to tell you that I started school nursing last year in mid-year (February) like you, and it is not easy to do so. There is a lot of on the job learning, and within months you will develop some personal protocols and policies beyond what is in the procedure manual. I had the first angry parent within a couple weeks of starting, and it can definitely throw you off, but hang in there! There will always be parents upset with you, even when you follow procedure and do everything right. Like the above nurses said, document document document and do your best!

One thing that helped me get over the "thrown to the wolves" feeling was reading any and everything I could on school nursing. Check out the NASN website, the threads in this forum, and your state department of health to see if they have a school health department. Keep breathing, next year it will get better!

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Specializes in medical/telemetry/IR.

I think you did everything right.

that lady sounds crazy.

I'm not a school nurse,

I love comng here and hearing all the crazy parent stories. I did a fewdays subbing as school nurse, my hats off to you'll.

but mine also has asthma.

I have spacer at school and home.

do we need peek flow at both? I don't even have one at home. I have my nebulizer at home. do you get the peek flows from the pharmacy with script?

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Specializes in School Nurse, Maternal Newborn.

At the conferences regarding respiratory problems in children, the consensus seems to be to always use the spacer, at least in elementary school children. The amount of medication lost, though the child may be correctly using the inhaler, is substantial. I have seen videos that show the differences in what actually gets to the lungs when using it-vs-not using. It is major.

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Specializes in school nursing.

"You can please some of the people some of the time but you cannot please all of the people all of the time."

It sounds like these parents want you to do something (control their daughter's asthma) that they are NOT being proactive about themselves. I.E. not following up with pediatrician after bronchitis. What else do they think you could possibly do? Plus, you have NO control after an asthma flare-up that happens later at home! This student was obviously not in any distress at all when the parent picked her up.

I would not worry - doesn't seem like you did anything wrong at all.

FYI - I always do a peak flow just to have that extra objective data on hand!!!

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Specializes in School, Hospice, Triage.

I'm sure that all of us reading your post have had similar situations. Even after six years in schools, I learn new things about myself and parents. Sometimes parents who haven't been doing all THEY should do for their child at home, feel the need to blame someone. That someone is the school nurse. You can only make decisions with the data available to you at the time. Not with what might happen later at home! You are not an extension of the parent. My corporation doesn't even supply peakflows or oximeters. My basic assessment involves lung sounds, respirations, distress, color and duration of symptoms. Calling the parent in this instance is appropriate. You did fine. Sometimes you can't please parents, no matter what you do. You won't be able to reason this one out. It won't be the last. It just comes with the type of work we do. You did fine.

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Poor girl, sounds like you have a parent that just wants to place the blame on someone. I've had almost the exact situation happen to me last year. A parent blamed me for an asthma attack the child had in the middle of the night. (I am also neighbors to this person and their child was riding a lawn mower all that evening before!). I'm not sure why they do this. Keep your head up!

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Yes, school nursing is a challenge. Hang in there, though. The kudos is worth the effort. After reading your message (yes, I read it all), I only saw one flaw. Next time call the doctor's office and ask them to send more orders with answers to all your questions. If they only give an order for three weeks that needs to be the cut-off. However, always call them to verify AGAIN.

You're always going to be dealing with fruity parents. Stick to what you know in your heart and experience to be best practice. :urck:

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Specializes in School Nurse, Maternal Newborn.

I forgot to mention: Lots of physicians don't use peak flow information. It can be useful, but ONLY if you have taken serial readings of the child when he is well, to see what his peak flow should be in the first place. A good peak flow reading for one child is not necessarily good for another child. It is recommended to do 2 weeks worth of daily readings, and come up with an average peak flow for that particular child. Then, when the child has an incident, you will know better whether his peak flow is compromised or not, and recheck peak flow 5 minutes after MDI dosing. HOWEVER, if the child says he or she is having breathing difficulty, even without wheezing, we are instructed by our school physican to give it anyway, providing it is not too soon for a dosing. Even so, the pulse oxymeter, which I am dreadfully jealous of you for having, BTW, should be the gold standard! You did NOTHING wrong in this scenario!

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I would be concerned that the child's out of the ordinary quietness was an early sign of an developing asthma attack because I have seen it in other kids. They will tell you they are fine and continue with activities, but are ominously quiet. One sign of an impending attack is tht the child responds using words rather than sentences Was her respiratory rate / heart rate elevated? Early on the elevated vital signs can be enough to keep the O2 saturation at 100%.

Did mom send in the asthma action plan now?

What do most of you do if the parents don't return asthma action plans for kids with inhalers?

The research shows that having a asthma action plan significantly decreases exacerbations, ER visits and hospitalizations

http://www.mhqp.org/guidelines/pedAsthma/pedAsthma.asp?nav=041319

But getting them sent in is a problem - what have you found works in getting them turned in.

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