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!
