Inhaler Use

[Achevy, BSN, MSN]

I've had some students with asthma this year that really make me question myself!  Yesterday's incident is on my mind.  My 6th grade student with asthma is recovering from a cold.  She had dance practice after school and would likely need her inhaler during practice.  Her mother told her to go to the nurse to take her inhaler at 1pm.  So the student came walzing into the office at 1 to take her inhaler.  She's congested and clearly recovering from a cold, but she's happy with no SOB or wheeze and pulse ox 98%.  My orders are for wheezing and asthma symptoms.  Would you have given her the inhaler knowing she would need it later and count the congestion as an asthma symptom? Are you very strict about following the orders to a T?  The student would not have come into the office asking for it, if mom hadn't told her to come.  I told the student to come at the end of the day when dance started, but she never did.  I stay worried that she needed it for her dance practice and I wasn't there and didn't let her have it earlier.  What would you have done?

[k1p1ssk, BSN, RN]

I will admit that I have given an inhaler prophylactically, even if my orders do not call for it specifically, however, if I am needing to do it more than once or twice, then I would usually call the family and/or provider and ask for new orders that state "PRN for cough, wheezing, SOB, or prior to gym/exercise." In our area, most of them come with this automatically, but occasionally the kids will get one prescribed from urgent care and the orders are not so good...

 

[Achevy, BSN, MSN]

k1p1ssk said:

I will admit that I have given an inhaler prophylactically, even if my orders do not call for it specifically, however, if I am needing to do it more than once or twice, then I would usually call the family and/or provider and ask for new orders that state "PRN for cough, wheezing, SOB, or prior to gym/exercise." In our area, most of them come with this automatically, but occasionally the kids will get one prescribed from urgent care and the orders are not so good...

 

Thanks for the reply!  It's my first year and being the only healthcare professional is strange sometimes.  Am I risking my license by operating outside of the orders? or am I risking my license by not treating the student and something bad happened? Thanks so much for the advice

[k1p1ssk, BSN, RN]

I mean, technically, yes, you would be operating outside of your scope of practice by not following the orders, however, in the school setting, you also need to use your nursing judgement and I think you will find a lot of us on this sub doing things "out of an abundance of caution". 

If in your judgement, a student would benefit from prophylactic doses of albuterol, you are well within your rights to contact the family and let them know. They may say "Go ahead! Please do!" in which case, I would just follow up with the MD and get new orders ASAP. You can even ask them to back date them. I've done that before and the docs have always been willing to do so, since they understand why I'm doing what I'm doing. 

In re-reading your original post, I am also thinking that part of this student's "plan" with her doctor might be q4h albuterol, which is incredibly common. Clearly, the mom is expecting that it be given in school at a certain time. And so, when faced with that situation, I might just call home and find out why that time specifically and why you're thinking maybe do it a bit later. It's possible that she goes to dance after school and mom meets her there with her home inhaler at 4 or 5pm, meaning she would be covered for dance! I don't know for sure, but there are a myriad of reasons why 1pm was specified by mom. 

All in all, when it comes down to these somewhat ambiguous situations,  clarifying things with families and their doctors prior to a medication admin is the best course of action, but we all know a lot the time there isn't enough time! In that case, you do whatever it is you need to do to keep them safe!