Do you ever say "no" to an inhaler request?

[JerseyTomatoMDCrab]

Do any of my school nurse pals ever encounter a child who so blatantly doesn't need their inhaler that you tell them they cannot have it? I'm curious.

[JenTheSchoolRN, BSN, RN]

I have not. I think the backlash could be pretty severe from a parent. I have given inhalers when I don't see a clinical reason to, but I can only assess chest tightness based on patient report. It would be the equivalent of refusing to give pain medication to a surgical patient who said their pain is 8/10 while chatting with friends. Sure it doesn't LOOK like the pain is so unbearable, but it's subjective.

Same. I have, though, encountered a student that was visiting me every day to use their inhaler that I suspected may be visiting me to get out of class, but wasn't sure (again chest tightness is reports only, no other physical signs of note seen on exam). I called home to report the increased inhaler use in school to the parent in case the same thing was happening at home and/or student was reporting any additional symptoms at home and follow-up was needed. Parent was surprised at the increase given student does not typically ever use the inhaler at home and was very appreciative of the call. Turned out student wasn't a fan of one particular class and the visits slowed with some help from home :).

[grammy1]

We have a handout that we got from the asthma clinic at our children's hospital called Rules of Two, we give these to parents for students that come in frequently.

--Does your child take his/her quick relief inhaler more than two times per week?

--Does your child awaken at night with symptoms more than two time per month?

--Does your student refill their quick relief inhaler more than two times per year?

--If you answered "yes" to any one of these questions, then your student's asthma may be out of control and they should be seen by their physician (unless they are required to take it before PE).

[kidzcare]

We have a handout that we got from the asthma clinic at our children's hospital called Rules of Two, we give these to parents for students that come in frequently.

--Does your child take his/her quick relief inhaler more than two times per week?

--Does your child awaken at night with symptoms more than two time per month?

--Does your student refill their quick relief inhaler more than two times per year?

--If you answered "yes" to any one of these questions, then your student's asthma may be out of control and they should be seen by their physician (unless they are required to take it before PE).

This is great!

[lifelearningrn, BSN, RN]

I have a student I told no because he was using it as an excuse to get out of class. I assessed him and when I asked why he felt he needed it he said because he got a sunburn over the weekend and felt 'hot'. I explained to him what the inhaler was for, and that it wasn't an appropriate treatment for a sun burn. With this particular student, I only give it if his complaints match the purpose of the medication.

[Jedrnurse, BSN, RN]

I don't refuse, but I will wait a bit if indicated. If lungs are clear and the peak flow is near their baseline (I check and document when students are feeling well), I have them sit and rest while drinking some water. Then I ask if they think they need medicine or if they're feeling better. Sometimes they end up wanting it, sometimes not.

[heinz57]

We have on occasion. Frequently, after running the mile at PE, they mistake SOB from running for asthma. If their lungs are perfectly clear we'll have them wait a few minutes and hydrate. That usually takes care of it. Then there are those that you can hear wheezing as they walk through the door--no stethoscope needed!

This drives me nuts! When the PE teachers are sending me kid after kid who just need to catch their breath on pacer day. Yes, running will make you short of breath. It DOES NOT mean that you need your inhaler.

There is a PE teacher here who keeps a pulse oximeter on her at all times (I didn't give it to her, no idea where she got it) and sends me kids with a note "Pulse ox 95%, needs inhaler"

I can't.

Wow! I used to make excuses for nurses who did this but that was before I worked PICU and witnessed a few children die of asthma.

Why is a child separated from their inhaler during PE?

Why aren't they bronchodilating before exercise if they have been diagnosed with Exercise Induced Asthma?

If they are wheezing, you screwed up by not allowing them to bronchodilate prior to exercise.

They may have air trapping which does not always wheeze. The SpO2 may not drop either. A decrease in SpO2 is a late sign and a very bad sign. You missed that window of opportunity. The PE teacher probably knows this which is why you have been given an SpO2 number.

What are the ages of all these kids who have their inhalers locked up in the office? We are going into 2017. Time to stop punishing kids for having asthma. I see 5 year olds who can tell me more about their medications than their caregivers can.

[grammy1]

Wow! I used to make excuses for nurses who did this but that was before I worked PICU and witnessed a few children die of asthma.

Why is a child separated from their inhaler during PE?

Why aren't they bronchodilating before exercise if they have been diagnosed with Exercise Induced Asthma?

If they are wheezing, you screwed up by not allowing them to bronchodilate prior to exercise.

They may have air trapping which does not always wheeze. The SpO2 may not drop either. A decrease in SpO2 is a late sign and a very bad sign. You missed that window of opportunity. The PE teacher probably knows this which is why you have been given an SpO2 number.

What are the ages of all these kids who have their inhalers locked up in the office? We are going into 2017. Time to stop punishing kids for having asthma. I see 5 year olds who can tell me more about their medications than their caregivers can.

Wow, way to fly off the handle. I did not see one post where a person denied a student their inhaler if there were orders to use it prior to PE. Do you think we don't assess before asking the student to hydrate and wait a few minutes? Did anyone here say that they would deny a wheezing child their inhaler?

As for those who carry them....99% of our students have written orders to carry their inhaler. When running at PE, their coach holds them-no pockets in their gym shorts. Why don't they use their inhaler at PE? My mom never refilled it, I forgot it, I can't find it, doctor won't refill it till I'm seen (haven't seen the doctor for 2-3 years), my brother/sister is using it now, I left it in my band locker, it's at my dad's house, I left it at grandma's last weekend, etc., etc., etc.

Some parents forsee this and keep an extra one in the clinic. That's great, unfortunately, those seem to be the students who rarely forget or lose theirs.

I'm so glad your 5 year olds know more about asthma than we do. I'm also happy that you live in the perfect world.

I found your post to be extremely rude and offensive.

[DEgalRN]

I have not, but I have a kid who I've told if he just wants to get out of class for a quick 5 minute break, please don't actually take your inhaler. I'm OK being part of the facade if he really just needs to stretch his legs.

[Flare, ASN, BSN]

As for those who carry them....99% of our students have written orders to carry their inhaler. When running at PE, their coach holds them-no pockets in their gym shorts. Why don't they use their inhaler at PE? My mom never refilled it, I forgot it, I can't find it, doctor won't refill it till I'm seen (haven't seen the doctor for 2-3 years), my brother/sister is using it now, I left it in my band locker, it's at my dad's house, I left it at grandma's last weekend, etc., etc., etc.

Some parents forsee this and keep an extra one in the clinic. That's great, unfortunately, those seem to be the students who rarely forget or lose theirs.

.

Yeah - this is a day in my world. My state only allows a child to carry their inhaler with MD sign off and parental sign off. Half the time I get the form back with the box either not checked or checked that they can't carry - even if they should carry because they are middle school and it's time (that is when i get a form back at all - we haven't discussed the kids that come in with the inhaler that they've had in their backpacks all year or the expired old inhaler they brought from home because they weren't feeling well this morning).

The other half of the time when i have a child that is permitted to carry, I am not supplied with an office inhaler. I do make it a point to discuss with every student that has a self admin and carry order that they are solely responsible for their inhaler and that I wasn't supplied one and that it is their responsibility to ensure they have it with them every day. They don't. not even close. Then when they are in asthmatic exacerbation it's up to us to figure out what to do with no inhaler available to them. You call the parents and tell them that their child is in crisis and has no inhaler and you're going to call ems unless there is a neighbor or someone close that can bring the meds - that's a hit or miss call. The parent ends up frustrated and surprisingly you'd expect that you'd have a spare in your office for that child the very next day, but in reality we all know that that only happens about a quarter of the time, if we're lucky.

I find inhalers all the time lost -no name. If i can, I try to be proactive by writing names with sharpies and covering with clear packing tape when i see the child the first time with the inhaler. I get precious few of them.

My overall point in this post - we do the best we can with what we're given - yet we're still given grief and the shoulda coulda woulda by people that are not in our trenches.

[Amethya]

I have a lot of PRN inhalers and only one that is needed each day. Still I do give it to them if they need them, I rather give it to them than face the consequences later from parents and admin.

But I had to confiscate some inhalers because of our school policy of them not able to hold their own inhalers. I seriously think we need to let them hold their own if there's a doctor's note for it.

[grammy1]

Yeah - this is a day in my world. My state only allows a child to carry their inhaler with MD sign off and parental sign off. Half the time I get the form back with the box either not checked or checked that they can't carry - even if they should carry because they are middle school and it's time (that is when i get a form back at all - we haven't discussed the kids that come in with the inhaler that they've had in their backpacks all year or the expired old inhaler they brought from home because they weren't feeling well this morning).

The other half of the time when i have a child that is permitted to carry, I am not supplied with an office inhaler. I do make it a point to discuss with every student that has a self admin and carry order that they are solely responsible for their inhaler and that I wasn't supplied one and that it is their responsibility to ensure they have it with them every day. They don't. not even close. Then when they are in asthmatic exacerbation it's up to us to figure out what to do with no inhaler available to them. You call the parents and tell them that their child is in crisis and has no inhaler and you're going to call ems unless there is a neighbor or someone close that can bring the meds - that's a hit or miss call. The parent ends up frustrated and surprisingly you'd expect that you'd have a spare in your office for that child the very next day, but in reality we all know that that only happens about a quarter of the time, if we're lucky.

I find inhalers all the time lost -no name. If i can, I try to be proactive by writing names with sharpies and covering with clear packing tape when i see the child the first time with the inhaler. I get precious few of them.

My overall point in this post - we do the best we can with what we're given - yet we're still given grief and the shoulda coulda woulda by people that are not in our trenches.

YES!!!

You've covered it all. Here it is, 4 days before Christmas break and we're still trying to get physician orders on some of these kids.

I love your idea of covering the name with packing tape, I will have to try that. I do use sharpie, but covering it is a great idea.

[grammy1]

I have a lot of PRN inhalers and only one that is needed each day. Still I do give it to them if they need them, I rather give it to them than face the consequences later from parents and admin.

But I had to confiscate some inhalers because of our school policy of them not able to hold their own inhalers. I seriously think we need to let them hold their own if there's a doctor's note for it.

Check the law in your state. Our state has a law that children MUST be permitted to carry their inhalers with physician consent.