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asthma assessment

Posted

Has 5 years experience.

What is your process for assessment when an asthmatic student says they're having trouble breathing or chest tightness?

I had a student come in earlier saying her chest was tight. I listened to her lungs and they were clear throughout. Pulse ox was 80, heart rate elevated, breathing even and unlabored with no retractions. No difficulties with speech. Does not use a peak flow meter at home. She took her inhaler and her pulse ox came up to 93. I have her coming back in a bit for reassessment.

I had her resting in my office for a bit and there she was doing fine, so I had her return to class. Asthma makes me so nervous when there are very little objective findings.

We have been trying to work with schools for over 3 decades to provide more resources for nurses, parents and teachers. The asthma educators website has some great links for assessment. It is much more than just using a beta agonist inhaler once in awhile. Identifying the bigger picture for at risk and proper maintenance is what we want to emphasize. Rescue and maintenance knowledge need to be assessed for provider, child and parent.

This link has alot of data but also some good assessment ideas.

https://www.google.com/url?sa=t&source=web&rct=j&ei=O_PUVK2oFpPcoASsn4GgDw&url=http://www.asthmaeducators.org/_resources/documents/events/2013_convention/improving%2520school%2520and%2520medical%2520home%2520asthma%2520care%2520rood.pdf&ved=0CDAQFjAC&usg=AFQjCNEzgYThJvY6DjSXoH-7vW73vBr8Sw

Association for Asthma Educators

Association of Asthma Educators - Home

The prep course, either online or seminar, is a great educational opportunity even if you don't take the certification exam. Due to the prevalence of asthma, I think this course should be encouraged for all school nurses.

Good book although I am hoping for a new edition to become available.

The Asthma Educator's Handbook:Amazon:Books

The ATS is also a great resource.

Excellent info on EPR3.

https://www.asthmaiq.org/epr3.html

Edited by GrannyRRT

A kid with SPO2 of 80% would typically present with more symptoms than just an elevated heart rate. Could your pulse oximeter need calibration or new battery? Just a thought. It sounds like you checked for other key indicators and your findings do not match what the pulse ox is telling you. When I have a questions about accuracy, I will take a manual pulse rate and see if it matches the heart rate indicated on the pulse ox. I will check if fingers are cold and if there is nail polish that needs to be removed. Some pulse ox monitors also take a minute or two to register the true reading so I typically leave it on for a bit to make sure.

I don't know. Just a few things to consider. I know I am confident in believing what my eyes and ears tell me and question if those handy gadgets do not correlate. They are great tools but not perfect.

SnowyJ, RN

Has 28 years experience.

It seems your assessment was very much like what I would do. I have a lot of asthmatics, and I don't hesitate to send them home if they are not stable, especially this time of year. I sent two home Monday who were getting over bronchitis and sounded horrible even after their neb. They both ended up on steroids. Much better now.

My goal is to get more education to the parents. Often they don't realize just how sick their children are!

OldDude

Specializes in Pediatrics Retired.

I use a pulse ox and find it to be very helpful but I depend on my eyes and ears first. The presentation you describe doesn't correlate with a pulse ox of 80. Regardless, you did the right thing by using the inhaler based on the symptoms the child was reporting.

kidzcare

Has 5 years experience.

She came in again and had pulse ox of 90 and no other symptoms. I know her very well since she is in everyday for her inhaler before PE and she is NOT the type to try to go home or attention seeking. I called her mom just to get her in the loop and the student talked to her and said she wanted to stay.

I asked her to come back in an hour for her inhaler (that would be the 4 hour mark since she last had it) and when she came in she just looked miserable. I couldn't get a reading on my pulse ox (it can be tempermental). Rapid respiration but still no wheezing or retractions. I called mom to pick her up just because I was getting a bad feeling on it, even after she took the inhaler again. I recommended that mom call their physician's office. She looked 50% better when she was leaving. I'm sure she'll fill me in on Monday of how she does over the weekend!

I haven't had any emergency asthma situations, but man do I get nervous sometimes with it in the school! At my other job we have oxygen tanks that we can have ready in a minute for a patient with low sats. Here I'd have to wait for the ambulance and I've read one too many story about a kid dying after schools didn't act fast enough. I don't what I would do if a child lost their life because I didn't act fast enough to call 911 or inject epi or something equally catastrophic.

The only time I have called 911 for respiratory was for a teacher. I think she was having a panic attack and her sats started in the 80s and then were in the 60s and I was freaking out until the ambulance got there with the O2!

JenTheSchoolRN, BSN, RN

Specializes in School nursing.

I've sent home a few students for asthma this year. One had an order for inhaler and neb, pulse ox will always read 97/98%, yet auscultate and the wheezing is clear as day. And it persisted after the neb, along with complaint of continued chest tightness. I've sent this student home three times this year, same story, and every time student was on steroids, did improve.

It turned out to be an allergy trigger each time as the day before student had visited someone with a dog and/or cat and the next day, boom, symptomatic.

Still, asthma will always continue to scare me, even as I try my best to find my resources (Thank you, GrannyRRT!). Hopefully that will keep me on my toes! :)

kidzcare

Has 5 years experience.

Thank you GrannyRRT for all that info!!

kidzcare

Has 5 years experience.

I've sent home a few students for asthma this year. One had an order for inhaler and neb, pulse ox will always read 97/98%, yet auscultate and the wheezing is clear as day. And it persisted after the neb, along with complaint of continued chest tightness. I've sent this student home three times this year, same story, and every time student was on steroids, did improve.

As soon as I hear wheezing, I call a parent. My son has really mild (Thank God!) asthma and when it is exacerbated (usually only if he has a cold), my doctor's office wants to see him immediately if he is wheezing.

Alnitak7

Specializes in retired from healthcare. Has 25 years experience.

When I'm confused about a patient I sometimes call their doctor. I'm gathering from these posts, that for certain reasons, not everyone does this.

Edited by Saiderap
to avoid misunderstanding

T-Bird78

Has 6 years experience.

Also ask if the pt has a daily maintenance inhaler they're supposed to be using. So many kids will stop using their daily because they're "doing good" and don't need it and can get very symptomatic in just a day or two. I've had pts confuse their rescue and daily inhaler, tell me they only use their Flovent/Advair/Asmanex/QVar/Dulera when needed but use the ProAir/Ventolin/Proventil/Xopenex BID. They then proceed to argue with me when I explain the difference. Anyway, SPO2 of 80 and only getting into the low 90s after a neb tx would be a call to a parent. I'm not a school nurse but am an asthma nurse so I get the other end of this situation. We'd give at least one round of neb tx, a shot of steroids, even epi in the office to help open them up then begin the regimen of oral steroids. I'd also see if you can get a new pulse oximeter since you even said it can be tempermental.

This again brings us back to asthma education.

If you are seeing this child almost daily, basic maintenance is probably not being done appropriately or poorly prescribed. How many know the appropriate dosage for maintenance inhalers? Most inhalers now have counters on so you and the child can keep a record. Have the child start a journal.

You need to be familiar enough with classifying the severity of asthma so you can get the message across to the pediatrician. You also need to ask the appropriate questions to identify possible triggers and make some recommendations through education.

Some Pediatricians are very bad at managing asthma. If we see a child frequently in the ED we will ask a Pulmonologist to follow up with the pediatrician after we do an asthma evaluation.

Another point that is disturbing in this discussion is when a rescue inhaler is still locked in the school nurse's office while the child is in PE or whatever physical exercise. We (Asthma Educators) emphasize to the child who is at risk to always keep their rescue inhaler close. Then, we hear they are reprimanded for carrying at school and it is taken away from them. We have fought with states for many years to get things changed but some just don't see the issue regardless of the numbers for serious asthma incidents.

Massmagic

Specializes in School Nurse. Has 8 years experience.

Granny RRT -

I agree with you about the inhalers being readily available to students. We have a rule in our district that all doors need to be locked when out of the room.

I do not lock my door when I go out of the med office as Inhalers HAVE to be available to all asthmatic students at all times. I have argued with other nurses about leaving door unlocked when not in office, they feel as if they just can't do that, and plus they feel like it is a medication that should be locked in their med cabinet as well.

I feel differently as inhaler access is essential. I keep inhalers in an unlocked cabinet and not in my med cabinet. I have the cabinet labeled in BIG letters and inform all students that their inhalers are in that particular cabinet.

I have many asthmatics but I have one that is a problem and mother fails to recognize the importance of daily long term inhaled medication (advair, flovent,etc). When I try to tell her that her son needs this daily, she gets angry. I think she feels as if I am telling her that she doesn't know how to take care of her child (even though she doesn't). I have resorted to teaching the student (6th grade boy) that he needs to step up and take responsibility in taking his Advair daily - every day even when he is feeling fine.

When he is having difficulty with tightness, his pulse ox ranges from 96-98%. A low pulse ox is a late sign of not getting enough oxygen. This boy knows how he feels and I can tell he is having difficulty by just looking at him. I always call his mother when he feels as if his chest is tight and having difficulty breathing. I tell her that I have done everything that I can for her son -rescue inhaler/nebulizer, and that he continues with chest tightness. I then let mom talk to her own son and I let him tell her how he feels. This has worked much better than me telling her what she should do. (Some parents are just hard to deal with). She always comes and gets him. She has never not come to get him. I try to do the best I can with each TYPE of parent. The mother making the decision has helped in this particular difficult case.

School nursing is a challenge - I do like this site as many of you school nurses have so much to offer. I learn so much from everyone. Great site.

kidzcare

Has 5 years experience.

This again brings us back to asthma education.

If you are seeing this child almost daily, basic maintenance is probably not being done appropriately or poorly prescribed. How many know the appropriate dosage for maintenance inhalers? Most inhalers now have counters on so you and the child can keep a record. Have the child start a journal.

Thanks for your response! I don't know if I put in the original post that the reason I see this student everyday is to use the inhaler prior to PE, per the asthma action plan. She uses a maintenance inhaler at home BID. The cold in our area has triggered more symptoms for her.

I also know that there is some stress at home. Parents divorcing and she is getting used to the back and forth between mom and dad's places and that is causing a significant amount of anxiety for her.

JenTheSchoolRN, BSN, RN

Specializes in School nursing.

As soon as I hear wheezing, I call a parent. My son has really mild (Thank God!) asthma and when it is exacerbated (usually only if he has a cold), my doctor's office wants to see him immediately if he is wheezing.

Oh, I called her. Every time. To be told: "did you do a neb treatment?" (The provider asks the same question). Wheezing is common for this student when exposed to an allergen the day before. Sometime the wheezing clears after a neb treatment (which I have an order for). Doc wants to see student if wheezing doesn't improve after a neb treatment, to which Mom comes asap to put student up and takes her straight to the doc.

Student also has anxiety issues, which can trigger asthma even more. I still call and follow the orders. Student's pulse ox has never dropped below 97% anytime.