Inhaler use prior to P.E.

Published

New to school nursing and I am trying to do things "by the books", which has apparently caused some upset with a parent or two. Elementary age student with asthma has proAir prescribed 2-4 puffs q4-6h PRN cough/wheeze. Student presents to clinic prior to pe requesting inhaler. Student says mom sent her since she had cough this morning. Student takes 4 puffs, with no pauses between and runs off to pe. I called parent to advise that I did allow student to use inhaler, however, I needed clarification order from Doctor if student needs inhaler prior to exercise in the absence of symptoms listed for use. I wasn't rude, just letting her know that isn't how it was prescribed and that the doctor could just fax over something clarifying in the event it was just omitted in error. The parent began to chastise me and in no so many words question my ability to do my job and said I was causing "problems" already. Fast forward, student comes in the following day, requesting inhaler prior to pe. No SOB, wheezing or cough noted. Lungs clear. Allowed student 2 puffs from inhaler and provided education to allow 30s to 1 minute before taking another puff. Student then went to PE. The student returned about one hour later (nearing end of pe) and was short of breath. Could have been the exercise or asthma or a combo. No wheezing or coughing. Allowed student remaining 2 puffs of inhaler. Instructed pursed lip breathing and monitored until sob discontinued. I am fairly sure I will be getting a call Monday and it will likely be worse. My thoughts are this 1)I am already technically going against physicians specific prescribed method, however, I also didn't want child going into full blown asthma attack because I refused inhaler. 2) I considered the likeliness of the increase in heart rate through exercise and medication and opted for 2 puffs since no symptoms were present. Can someone please shed some light on this? I am dreading the parent communication when I get the call that the child had issues because I didn't give 4 puffs. I don't know how to deal with the parent who apparently gives the child the inhaler frequently in the absence of symptoms as well as max puffs and improperly (consecutive puffs with no pauses). I hate that it's my first week on the job and there is already a parent I can tell will give me grief all year long and probably go complain to principal about me. I am a parent myself so I understand how we often know our own children better than strangers. On the flip side, I have a license to protect and nursing judgment to guide me in making decision with children that are not my own. Help!!!

Up Vote Up Vote ×
Specializes in ICU, trauma.

I'd just like to start of by staying I am completely unfamiliar with the world of school nursing, however I have been a severe asthmatic/athlete my entire life. I'm not sure what age of school age child you a dealing with but I frequently ran into issues with my school nurse as well (starting in elementary) . Issues such as not being able to use my inhaler when I thought needed etc. If you're administering the prescribed dose I wouldn't be too anal about it. Just because you don't see any coughing or ascultate any wheezes doesn't necessarily mean they are asymptomatic and not feeling short of breath. Maybe get the order changed to "prn for sob/wheezing" to cover yourself.

Up Vote Up Vote ×

Thank you for your advice. I didn't want to deny her to use of her inhaler prior to pe. My thought process in giving 2 puffs vs 4 was that when the student (around 8 or 9 y/o) initially presented she wasn't short of breath, wheezing, or coughing...I knew her asthma could potentially be exacerbated during pe so I opted for 2 puffs. Since the dosing was 2-4 every 4-6 hours prn coughing/wheezing I felt like giving her 4 puffs initially wouldn't allow me to give additional puffs should she return after pe requesting it. When I looked up Davis drug guide as well as the medication insert the recommended dosing was 2 puffs prior to exercise. I've learned with most medications not to start off with the max dose unless there is a clinical indication to do so. Paradoxical bronchospasm is noted as a potential adverse affect with the excessive use of inhalers. Am I completely off here? School nurses, do you typically give 4 puffs to students prior to exercise?

Up Vote Up Vote ×

The order probably should be rewritten with an Action Plan. Many RTs, Asthma Educator RNs and Asthma educators will instruct patients to take their Albuterol or Levalbuterol inhalers 15 minutes prior to exercise. This is pretty standard per the EPR 3 Asthma guidelines and should be listed on an Asthma Action Plan. Actually, the Asthma Action Plan should accompany any script to be used as a guideline. This is extremely important. The plan should fit the child and the activity and not some tired old only q6 prn and only if wheezing order. This just limits the child and enforces poor coping/management techniques.

The number of puffs will be determined by the child's severity (see the EPR) and response from an Exercise Test which may have been done in a PFT Lab. Again the old 2 puff orders do not fit everyone. It is not uncommon for kids to be discharged on 4 puffs of albuterol and tapered as their maintenance medications are regulated. In the hospital, asthma protocols start at 8 puffs of albuterol q 2 hours.

Take an Asthma educator class. I think the AE-C should be required for all school nurses since asthma can kill and is so poorly understood by several health care professionals and EMS providers.

Up Vote Up Vote ×
Specializes in Pediatrics Retired.

Occasionally I see a bona fide case of EIB on the elementary level but it is very occasional and usually manifests as a result of recess, where kids exert themselves many times greater than they do at PE. But what do you hear from the physicians...2 puffs prior to PE or "exercise?" Most of the orders to pre-treat for EIB on the elementary are unnecessary and have arisen from a single office visit to the pediatrician resulting in a great dis-service for the child and creating an unnecessary dependency on using the inhaler; and usually using it in a ridiculous manner, pumping the inhaler twice and a brief inhalation with no spacer and everything is good. I get the same thing where asthmatic kids have been brain washed into thinking if they run, they start to breathe heavily and thus they have to scream to the nurse office and use their inhaler - lungs clear, no wheezing, respiratory effort what you would expect for the level of activity in any kid, yadda, yadda, but they have been taught to be inhaler dependent. I understand asthma, EIB, EIA, etc. I did my time in a pediatric pulmonology clinic so don't start the dog piling, I appreciate the need for bronchodilators. Remember we're talking the elementary level.

So, Jen...don't worry about it. Just do what the MD paper says and move on.

Heinz...I hear ya. I respect and appreciate what your offering and agree with ya. Just keep in mind these little guys don't even know how to spell asthma, much less how to generate an accurate PFT effort.

Up Vote Up Vote ×
New to school nursing and I am trying to do things "by the books", which has apparently caused some upset with a parent or two. Elementary age student with asthma has proAir prescribed 2-4 puffs q4-6h PRN cough/wheeze. Student presents to clinic prior to pe requesting inhaler. Student says mom sent her since she had cough this morning. Student takes 4 puffs, with no pauses between and runs off to pe. I called parent to advise that I did allow student to use inhaler, however, I needed clarification order from Doctor if student needs inhaler prior to exercise in the absence of symptoms listed for use. I wasn't rude, just letting her know that isn't how it was prescribed and that the doctor could just fax over something clarifying in the event it was just omitted in error. The parent began to chastise me and in no so many words question my ability to do my job and said I was causing "problems" already. Fast forward, student comes in the following day, requesting inhaler prior to pe. No SOB, wheezing or cough noted. Lungs clear. Allowed student 2 puffs from inhaler and provided education to allow 30s to 1 minute before taking another puff. Student then went to PE. The student returned about one hour later (nearing end of pe) and was short of breath. Could have been the exercise or asthma or a combo. No wheezing or coughing. Allowed student remaining 2 puffs of inhaler. Instructed pursed lip breathing and monitored until sob discontinued. I am fairly sure I will be getting a call Monday and it will likely be worse. My thoughts are this 1)I am already technically going against physicians specific prescribed method, however, I also didn't want child going into full blown asthma attack because I refused inhaler. 2) I considered the likeliness of the increase in heart rate through exercise and medication and opted for 2 puffs since no symptoms were present. Can someone please shed some light on this? I am dreading the parent communication when I get the call that the child had issues because I didn't give 4 puffs. I don't know how to deal with the parent who apparently gives the child the inhaler frequently in the absence of symptoms as well as max puffs and improperly (consecutive puffs with no pauses). I hate that it's my first week on the job and there is already a parent I can tell will give me grief all year long and probably go complain to principal about me. I am a parent myself so I understand how we often know our own children better than strangers. On the flip side, I have a license to protect and nursing judgment to guide me in making decision with children that are not my own. Help!!!

Do not allow the parent to be huffy or rude.

Cover yourself, keep your license, get the orders you need to do that.

Up Vote Up Vote ×
Occasionally I see a bona fide case of EIB on the elementary level but it is very occasional and usually manifests as a result of recess, where kids exert themselves many times greater than they do at PE. But what do you hear from the physicians...2 puffs prior to PE or "exercise?" Most of the orders to pre-treat for EIB on the elementary are unnecessary and have arisen from a single office visit to the pediatrician resulting in a great dis-service for the child and creating an unnecessary dependency on using the inhaler; and usually using it in a ridiculous manner, pumping the inhaler twice and a brief inhalation with no spacer and everything is good. I get the same thing where asthmatic kids have been brain washed into thinking if they run, they start to breathe heavily and thus they have to scream to the nurse office and use their inhaler - lungs clear, no wheezing, respiratory effort what you would expect for the level of activity in any kid, yadda, yadda, but they have been taught to be inhaler dependent. I understand asthma, EIB, EIA, etc. I did my time in a pediatric pulmonology clinic so don't start the dog piling, I appreciate the need for bronchodilators. Remember we're talking the elementary level.

So, Jen...don't worry about it. Just do what the MD paper says and move on.

Heinz...I hear ya. I respect and appreciate what your offering and agree with ya. Just keep in mind these little guys don't even know how to spell asthma, much less how to generate an accurate PFT effort.

I respectfully disagree with what you have stated.

Do you actually know how exercise testing is done? Do you know how extensive the education is for many of these kids? This is not the 1970s.

Have you looked at the statistics for asthma deaths of school age children? Yes, elementary school kids die also from asthma. Have you ever sat with the parents of a child on ventilator from an asthma event for which they will not recover? Don't preach this is made up bogus stuff. Maybe some doctors do over react but then maybe they don't. With the number of kids having asthma, it is difficult to reach everyone with the appropriate teaching especially if other providers would rather criticize than find an alternative solution.

IF you have seen kids doing poor technique, what have you done to correct it?

Did you know that not all asthmatics wheeze when they are short of breath?

Why do your kids still have to come off the athletic fields to "scream" to a nurse's office for their inhaler?

Your system seems very broken and probably doesn't benefit the kids.

I again with tell anyone working with pediatric asthma patients to take the Asthma course and learn the alternatives and latest guidelines rather than taking advice from an anonymous forum with a few very obviously burnt out nurses.

Up Vote Up Vote ×
Specializes in Pediatrics Retired.
I respectfully disagree with what you have stated.

I agree with you that you disagree with me.

Up Vote Up Vote ×
Specializes in School Nurse. Having conversations with littles..

Nurse.jen- By all means protect the child and your license. Set the tone early in the year. Follow the order. Hope the parent can get the dr. to provide the order that meets the needs of the student while at school. If the parent can't do this. I always, always, always offer for the parent or other designated care giver to come and administer the the medication in question. Offering this option does not deny the student the medication. It just puts the ball in the parents court, while they help come up with a solution. Make sure to provide a schedule of the student's PE and recess schedule. Just a thought....but, are nurses in other practice settings considered "burnt out" because they request clarifications for orders?

Up Vote Up Vote ×
Specializes in School Nurse.

Personally, I would FAX the Medication Order to the physician with a request to modify it to include pre exercise prevention, per parents request. This takes me just a few minutes. I might even place a phone call to alert the clinic nurse that I am sending the request - Use the "If you are a healthcare provider, please press 1" button. I get much better response doing this than having the parent call. and it sets up a good pattern of communication because they appreciate it.

Up Vote Up Vote ×

In Oklahoma, state law is that kids can keep their inhaler with them and use when they would like as long as the parents (and the school) agree that the child is able to safely self-administer. The same law also covers Epi-pens

Up Vote Up Vote ×
Specializes in School Nurse. Having conversations with littles..
In Oklahoma, state law is that kids can keep their inhaler with them and use when they would like as long as the parents (and the school) agree that the child is able to safely self-administer. The same law also covers Epi-pens

It is the same in Missouri, but all the T's have to be crossed and the I's dotted on the paperwork.

Up Vote Up Vote ×
+ Join the Discussion