Asthma Question

Specialties School

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I have a student, an asthmatic, who was recently put on Advair (takes that at home), uses an Albuterol inhaler PRN and also has an order for Albuterol nebs PRN. She is a very gregarious and charming 7th grader that I have gotten to know fairly well during the school year.

She comes to my office at least once a week c/o "tightness" and "wheezing." She is never SOB and upon listening to her lungs, I have never ONCE heard anything remotely sounding like a wheeze. I used to just have her sit "catch her breath" using some breathing techniques I've seen RTs do in the hospital and send her back to class never to hear from her again for the rest of the day.

Anyway, mom called me the other day and asked me (nicely, I might add) to please give her daughter a treatment whenever she wants it b/c "it makes her feel better." Mom also said that if she doesn't get a treatment when she c/o "tightness" that it is a s/s of the begining of a real, true, massive asthma attack. She also said that her daughter "always gets like this, this time of year (spring)." Mom denies that the student has any allergies but said that she'd be taking her daughter to the doctor over easter break. I took the inititive today and called the MD myself to ask him what he thought about mom telling me to give her nebs. Unfortunately, he wasn't very familiar with her case and wasn't able to help much. Except he was nice enough to say that he'd recommend allergy testing and would talk to her about exactly how much medication she's getting at home.

So, am I right to be wary about not giving this student a PRN neb who is: in no apparent distress, not SOB, not wheezing, and is talking, singing and fooling around in my office just b/c mom says she wants her to have it. I know that if she were a pt in the hospital and I called RT to come and look at her they'd tell me I was crazy and would NEVER give a tx unless it was ordered RTC. Is it possible that she is being overmedicated at home and her parents are enabling her? Am I being overly cautious? I feel like I'm doing something wrong.

Most important question: AM I MISSING SOMETHING HERE??????

Thanks,

Deb B.

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Specializes in MS Home Health.

For me, and I have been asthmatic since the age of 2 (now 46) wheezing comes late for me and I am in real trouble by them. I get tight fast, cough then wheeze, if I don't do it when the tight hits, I can still talk and such, I am in deep doo doo. I will be blue in minutes. I seldom wheeze but I always always cough. Does she cough? As a kid I was hard to pin down even in some of the attacks.

renerian

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What is the protocol you have worked up for her? What do you have in her care plan? I would send the care plan to the doctor with the next visit and get it updated. Are you doing peak flows? I agree with renerian, is she coughing at all? How often? Clearing her throat? She does not need to be showing anxiety or wheezing to be able to detect an attack or exacerbation coming on. I would be very hesitant to withold a treatment if she is feeling tight . For some kids, by the time they are wheezing, you are flirting with an ER visit, or worse. I have been able to trust children's judgement. I have not ever had a kid malinger about asthmatic symptoms. Has anyone else?

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I'd have to agree and opt for giving the tx..better to give and prevent full blown attack...she is old enough to know her s/s and progression of an attack.I've see pts actually have an asthma attack when tx prolonged r/t stress and fear.As long as she has tx ordered by MD prn I'd give her one...maybe I'm wrong..I'd surely keep in close contact with her parents/MD about her asthma...when in doubt you can always consult with her MD :)

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Specializes in pre hospital, ED, Cath Lab, Case Manager.

Like Renerian, I cough, don't wheeze until I'm in real trouble. I can be "tight" and still function fairly normally. And yes, while working in the ED I have seen teenagers use their asthma as an attention getting behavior. Better safe than sorry I would say, a full blown asthma attack is pretty scarey. Calling the MD was good to alert him that maybe her meds need to be changed. Advair has a great outreach program for asthma education it's called "on the Go". Allergy testing sounds like a good idea. Hope this helps:)

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Specializes in Peds, Pre and post op.

Why not give her a peak flow while she is breathing good (take 3 numbers and get the average) to establish a baseline for her normal breathing capacity.

Then when she has breathing trouble have her do the peak flow and compare it to her normal baseline score.

Also do some patient education on the mother & daughter as to how taking the meds when she doesnt need them is bad, the side effects to the meds, ect to teach them how important is is to only use them PRN not whenever she feels like it. Also teach them as to why the peak flow is important and how it helps you and them (as a child a RT lied to me and told me my peak flow would prevent attacks if I used it all the time, I knew she was full o' crap so I never did my peak flow at home becuase it felt unnesessary) .

Many asthatmatic people (myslef included) can tell when an attack is coming on an prevent it by using thier albuterol (or other bronchodilater) inhaler before things get worse. This might be what the girl is doing but she may be taking i unnecesarily (to get out of Pe or another class?). HTH :)

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Specializes in MS Home Health.

Peak and flows would be good...........good thought.

renerian

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I am a school nurse in an urban area and I have this problem constaltly. I think sometimes kids come to my office to take asthma medication just to get out of class. I usually do not hear any wheezing, and they do not appear to be in any distress much of the time. In this situation I let them sit in my office for a few minutes and have one puff of the albuterol inhaler. I look at them for a while after using the medication, and they are usually calm and ready to go back to class. I would not be able to defend myself if the child asked for her medication and I refused to give it!

I don't know about your school district, but mine does not budget for peak flow meters, and the children do not have their own either! I would love to be able to do that kind of follow up on the students.

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Give the treatment, if somthing happens youwould be sooooooo screwed if you didn't. My 6 year old asthma presents as a coughm, almost never has wheezes. Nebs take care of it right away

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Well, I've never seen her cough either....to answer everyone's question!

We don't budget for peak flow meters either. I'll ask mom if she would be able to provide one though.

I guess I'll just go ahead and medicate her whenever she asks. Cause it seems like everyone is an agreement that her s/s may very well lead to a real attack!

Thanks for the help!

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Mrs. B, if you have a group of students with asthma you may want to contact the Nassau-Suffolk Lung Association about doing an open airways program in your school. It consists of six lessons on preventing & managing asthma attacks. The children enjoy it & they learn so much.

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I have one in my school that will come in (maybe once a month) and say "I need a breathing tx". I get his stuff out and we do it. I won't take any chances with this. We had a child die outside our district because noone did anything. I will not let this happen if I can prevent. By that age, most kids now their problem and can tell you how to deal with it.

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