Asthma attacks and no albuterol.

[pineappleupsidedowncake, BSN, RN]

Let me first preface this by saying I am new to school nursing, let alone new to pediatric nursing. 

I had this happen way too many times this year, with a few of the same asthmatic kids. They come from PE having an asthma attack and no albuterol available at school. I always call the parents right away and put the pulse ox on. I do my assessment, have the kid try to calm down and take deep and slow breaths. It has never been "severe enough" to warrant EMS. In 100% of the cases, the student will approve naturally or they have their medication (illegally) in their backpack. In the case they do have their inhaler but no physician note, I just have them use it... I couldn't imagine doing otherwise. But it still makes me feel uncomfortable giving meds with no orders!

I have followed up with the parents quite a few times about having the doc sign the necessary forms so that they can have their meds at school. Usually the parent will say that the doctor does not have any open appointments or they have an appointment scheduled for this weekend.... but then it ends up "getting cancelled." I am not trying to judge or assume but I am not naïve either. What else can I do? And should I be calling 911 if they don't have their medication?? Of course I would call 911 if there was no improvement or the kid appeared to be getting worse, but that is never the case. I also feel like every time a parent comes to pick up their kid and they have already almost completely improved, it just makes the situation worse... 

Anyways, what would you do? Am I getting too stressed over this? Is this a common situation? 

[BrisketRN, BSN, RN]

When possible I get permission from parents and fax forms over to the doctor or get permission (we don't technically need it, but most docs won't talk to me without it) to discuss the child's medical condition with the doctor. If students are older they can self carry & self administer when permission is given by doctor, parent, and they show me they know how to use their inhaler properly & parameters for when they need to come see me.

Also--yes this is common.  It's like pulling teeth trying to get the paperwork.  I'd 100% also let them take the inhaler if struggling breathing & I don't have the paperwork.  Tell parents "if their oxygen saturation doesn't improve/continue to struggling breathing after X minutes/etc then we will have to call EMS for your child's safety."  That ambulance bill threat might get you paperwork quickly. 

[ruby_jane, BSN, RN]

Don't be the nurse who takes away the inhaler! But do get the administration involved.

This is one of those frustrating things about school nursing - the reliance on the albuterol inhaler and the lack of preventive care (if you're needing your albuterol inhaler on the daily, the preventive isn't working or the kid isn't taking it).

At the beginning of the year I pull all the health conditions and call or email parents of kids who have asthma. Half of them do not have an inhaler because it's been years since the last asthma attack. Some of them only have one inhaler and no spare to send. Some don't answer me. But I document the contact and that parent is "declining to provide medication to the school clinic. Parent verbalized understanding that in an emergency, nurse will call EMS."

Do not be afraid to call EMS if the student is tripod posturing, lips are blue, or if you hear adventitious breath sounds before (or even after) they administer their albuterol. Or if they've used the inhaler but have no relief. Especially now!

[Jedrnurse, BSN, RN]

Def-Con 5 scenario would include filing with child protective services for medical neglect. (That's an absolute last resort and only in very particular circumstances...)

[ruby_jane, BSN, RN]

On 11/13/2020 at 8:23 AM, Jedrnurse said:

Def-Con 5 scenario would include filing with child protective services for medical neglect. (That's an absolute last resort and only in very particular circumstances...)

Also be careful of how you use Def-Con 5.... In Texas you do not have to prove neglect, just have to suspect it. But there are a hundred different scenarios about why the kid doesn't have the inhaler and many of them start with the parent being unable to afford the visit to get the prescription....

[LikeTheDeadSea, MSN, RN]

Do you have a district physician who can write a Standing order for inhaler use for known asthmatics if their inhaler is present?

It's a nice CYA if you already know they have Asthma and that sneaky inhaler is in the backpack.