Inhalers?

KelRN215, BSN, RN · Mar 27, 2015

I have a ton of students with inhalers, here at school, but I have a handful of kids who only use them when Mom tells them they need to. For example, I have a student coming in to use the inhaler because of a cough. Mom instructed the student to start using the inhaler. Am I wrong in feeling a little frustrated with this? No signs of distress, able to speak in full sentences without gasping for air, comes be-bopping in when ready to use. Maybe I'm wrong and we are preventing some full blown episode but I really have mixed feelings about this one.

Well how old are these children? Most children need some sort of guidance from an adult in this sense. It's not like a child can say on his own "I think I am getting sick. I usually have asthma exacerbations when I have a URI. Therefore I should start using my inhaler." Wouldn't you rather prevent than treat?

pfongk · Mar 27, 2015

I found out this week that my 5 yr old is able to keep his puffer on him at school. I've chosen for him not to have it on him, but his teacher is keeping it for him in the classroom and it then gets handed to the teacher on playground duty to give if he asks for it. He's had a puffer/nebuliser on and off since he was under 1 (asthma only flares up when unwell or during cyclones). He knows how to take it and has actually come inside from playing at home to sign to me that he needs it. He'll probably keep it on him full time when he's about 8 and I can trust him not to lose it.

Red Kryptonite · Mar 27, 2015

"You're not in distress."

Any nurse who said this to my asthmatic kid would find him/herself in the headmaster's office attending a meeting where I am demanding their firing.

JenTheSchoolRN, BSN, RN · Mar 27, 2015

I will share some of the attitudes I face when trying to educate other health care professionals (esp nurses) and the comments I hear from kids. At first I used to give the School Nurses the benefit of the doubt but then after hearing the same comments from several children, I could predict what some were going to say based on their school and the nurse.
"You don't need an inhaler. You are talking."
"MDIs are useless. If you really had a problem they would have given you a nebulizer."
Or,
"If the kid had nebulizer instead of that pos inhaler I wouldn't have to call the medics."
"If you have to take an inhaler before playing sports then you probably shouldn't be playing sports."
"You'll lose your inhaler."
Yes some kids do lose their inhaler. But some also are not even given the chance to lose their inhaler. We try to issue a clinical (smaller total # of sprays) inhaler for them to carry or to have as a back up at school. This gives them the opportunity to be accountable for when they use it or lose it.
"You have to wheeze to be having an asthma attack."
"They're on an inhaler."
For a more simple review of what we teach the child, for those who don't want more details, here is a link which covers what we tell the parent and the child.
Handling an Asthma Flare-Up#

Wow. What kind of nurse, school or otherwise, would say these things?

However, I have worked with students that lose their inhaler. Or leave it at home vs. keeping it on their backpack at school per the plan. I will say, though, these kids usually also don't understand why it is important to keep their inhaler with them. With those kids, I sit down and take out their asthma action plan to discuss what it means and why having an inhaler with them is very important.

I also call up the parent, explain self-carrying issues and try to get the student to self carry with a back-up in my office. Of course, if the parent does think their kid's asthma is important, that can reflect right back into the child unfortunately.

(I work with HS kids that need to transition into their own health care management in college and I do think that is a very valuable skill a school nurse can help a student develop.)

SnugglePuggle, MSN, RN · Mar 27, 2015

This is a great thread! Thank you for GrannyRRT for such important insight. I work in a Middle School and even at that age only about half of my student with asthma self-carry. The student must be deemed responsible enough to self-carry by the physician and the parent. I never refuse a student their inhaler or make them jump thru hoops to get it. That being said, I have had the student who abuses clinic privileges and uses asthma as a reason to get out of class. If I suspect this is occurring I just give the parent a call to discuss the frequency/timing of inhaler use. Open communication is so important. Equally important is maintaining a non-judgmental attitude towards these kids. We do not want them questioning the the way they read their own bodies.

Supernrse01, BSN · Mar 27, 2015

I in no way made this student to feel stupid or inadequate. I feel as though I asked appropriate questions to determine all the facts. You make great points; however, this particular student does not follow a schedule at home, nor do they take an oral steroid. This dosage has not changed since we first met last year.

Most students carry their inhaler with them; after the proper paperwork has been completed. This student keeps the medication in the clinic, at the request of Mom.

Supernrse01, BSN · Mar 27, 2015

He does have an action plan but that is not part of it. Thank you for mentioning that, I need to make sure that we add that in for this student, especially since it looks like something that may have changed since we first developed the plan.

If I let some of the kids carry their own inhalers, they would lose them, so i have some in my office by parent request. But they aren't locked up. I have an inhaler wall - a snow with a slot for every inhaler (and/or Epi-pen) for easy, fast access by any staff member. My office door does have a code on it, but the code is known by all office staff.
And I have quite a few students that per their asthma action plan are to use their inhalers every four hours if sick with a cold, allergy flare-up. I request the asthma action plan as part of the asthma paperwork (along with medication order for the inhaler). Does the child have one?

Supernrse01, BSN · Mar 27, 2015

Definitely, KelRN215. I was just wondering how many of us see students coming in for that preventative reason. I didn't deny the child and encouraged the student to let talk to me about any changes that may be taking place.

Well how old are these children? Most children need some sort of guidance from an adult in this sense. It's not like a child can say on his own "I think I am getting sick. I usually have asthma exacerbations when I have a URI. Therefore I should start using my inhaler." Wouldn't you rather prevent than treat?

Supernrse01, BSN · Mar 27, 2015

Completely agree! Please let me clarify that I did not deny this student the inhaler. Like you, I have a few students who often seem to be abusing the inhaler in order to get out of class. I'm not denying student's their medication and I won't speak to them they way some of the examples are written. I want them to trust me.

This is a great thread! Thank you for GrannyRRT for such important insight. I work in a Middle School and even at that age only about half of my student with asthma self-carry. The student must be deemed responsible enough to self-carry by the physician and the parent. I never refuse a student their inhaler or make them jump thru hoops to get it. That being said, I have had the student who abuses clinic privileges and uses asthma as a reason to get out of class. If I suspect this is occurring I just give the parent a call to discuss the frequency/timing of inhaler use. Open communication is so important. Equally important is maintaining a non-judgmental attitude towards these kids. We do not want them questioning the the way they read their own bodies.

NutmeggeRN, BSN · Mar 27, 2015

During my almost 4 decades as a pedi/neo RRT, I have heard and seen a lot. Participating in the campaign to get legislature passed for inhalers in the hands of kids at school was a biggie. It also showed me what opposition the pro side was up against from the nurses in some schools. But, that gets into the political side. I have seen the size of some school campuses and can not imagine waiting for someone to bring the inhaler or to actually have to walk the length of a couple of football fields to get it.
I will share some of the attitudes I face when trying to educate other health care professionals (esp nurses) and the comments I hear from kids. At first I used to give the School Nurses the benefit of the doubt but then after hearing the same comments from several children, I could predict what some were going to say based on their school and the nurse.
"You don't need an inhaler. You are talking."
"MDIs are useless. If you really had a problem they would have given you a nebulizer."
Or,
"If the kid had nebulizer instead of that pos inhaler I wouldn't have to call the medics."
"If you have to take an inhaler before playing sports then you probably shouldn't be playing sports."
"You'll lose your inhaler."
Yes some kids do lose their inhaler. But some also are not even given the chance to lose their inhaler. We try to issue a clinical (smaller total # of sprays) inhaler for them to carry or to have as a back up at school. This gives them the opportunity to be accountable for when they use it or lose it.
"You have to wheeze to be having an asthma attack."
"They're on an inhaler."
For a more simple review of what we teach the child, for those who don't want more details, here is a link which covers what we tell the parent and the child.
Handling an Asthma Flare-Up#
From the link:
It is unfortunate when kids do go to the School Nurse and are told things which contradict what they have been taught. Yes, that does make them feel embarrassed and stupid depending on your delivery. "You're not in distress."
I encourage School Nurses to read through some of the links I have posted here in other discussions about asthma and inhalers. I also encourage you to take the steps to become Asthma Educators so you can better open the lines of communication with the Asthma Educators working with Pediatricians and Pulmonologists. Just following orders or a plan of action is not always enough. You should also understand how that plan was derived so you can better assist the students.

Well then, in my experience, you are the exception to the rule. Whenever there is an inhaler prescribed, I ask for an asthma action plan. I have waited months for them, despite repeat requests to the MD office. I have dropped off our permission forms and action plans to have in the office. I worked in a family practice office and we gave out the low number inhalers for school purposes.

I believe what Old Dude meant was:

OK do what you need to do in the moment, but if it is to be continued, we are required to get the prescription/orders on file at school. I will let a kid use an inhaler as needed and work on the paper work. I do not believe there is a school nurse who would knowingly withhold needed treatment. Could some of us be better educated? Probably.

I have also had kids (HS Age) using their MDI inappropriately and have had to do extensive teaching with them. It does not clear a head cold out. This to a student whose o2 Sat was 100, lungs sounds were clear in 4 quadrants, not a wheeze to be heard and great air exchange, no retracting, no Sx air hunger etc

We as school nurses also have to deal with parents who:

1) neglect to advise us of a diagnosis

2) neglect to fill out paperwork when hand delivered, mailed or faxed, sent electronically or what have you

3) continue to smoke in he home and the kiddo comes in reeking of smoke on their clothes

4) acknowledge the child smokes but states "I have no control over her she is 17"

Please do not make broad assumptions about the care provided in the school setting.

abc123RN · Mar 27, 2015

We as school nurses also have to deal with parents who:

1) neglect to advise us of a diagnosis

2) neglect to fill out paperwork when hand delivered, mailed or faxed, sent electronically or what have you

3) continue to smoke in he home and the kiddo comes in reeking of smoke on their clothes

4) acknowledge the child smokes but states "I have no control over her she is 17"

Please do not make broad assumptions about the care provided in the school setting.

This is the hardest part of taking care of the asthma kids....parents not working with the school nurses. Parents that don't share info, respond to request for info make me want to scream!!

Flare, ASN, BSN · Mar 27, 2015

in my state, children are allowed to self administer if signed off by the doctor and parent. I usually start pushing this at around 6th grade if the student hasn't been deemed responsible and capable prior to then. I'd rather the children carry their own inhalers - especially once they are in middle school. Most of the kids play after school sports and I am not here for their inhaler needs. In my state only a RN the school doc or a parent may medicate a child (or they may self medicate certain approved medications) so keeping inhalers unlocked would be a moot point.