Bizarre Med Order

[UrbanHealthRN]

This is actually a kiddo on the daycare side, not preschool side, of my agency. And actually, he's a 4 month old baby, not kid. But anyways. Has bad reflux that's not under control plus I guess had a cold 6 weeks ago that involved some wheezing. Has been on multiple daily albuterol nebs ever since the cold started, and hasn't stopped. I'm new to this job, just found out about this kiddo on Friday, and have been working to make sure all med paperwork etc. is in place.

Checked him out today before the time that staff would usually give him a neb (here, classroom staff can give meds, not just a nurse), and he sounds totally fine with my stethoscope. No reason I can see in that moment to give him albuterol. He gets the neb, cries and fights it the whole time, and of course is coughing and refluxing by the end of the treatment.

I think to myself, no way did the doctor mean it when she prescribed albuterol as "give one vial every four hours" (no prn, no give for xyz symptoms), so I call the family and they call the doc. Nurse from the doc's office calls me back and is super rude, basically telling me my assessment means nothing, I don't know anything about this baby, and how dare I not follow doctors orders by not giving albuterol exactly every four hours? (Um, even the parents aren't doing q 4 hr treatments, but I guess I'm the bad guy here...) She tells me that this baby is going to need to continue q 4 hr, around the clock, albuterol treatments for probably another few months before they can cut him down to prn.

Ok. Rant over. Am I crazy? Have any of you seen a kid get this much albuterol before? I was so taken aback by her tone, I kind of just said sure, thanks for the clarification, we'll get on it, but I reallllly don't feel ok about this. Staff are going to be treating this baby 2 to 3 times daily, and for what? I guess the family is pretty worn out trying to manage his health problems, and is tired of communicating with staff about his daily condition and concerns, but I'm almost wondering if I can say this is nuts and my nursing license and staff aren't going to be involved with this medication nonsense.

[UrbanHealthRN, BSN, RN]

Friend of mine had a nurse tell her that her surgical wound post op was fine (this was over the phone and wound was never sighted)

2 days later my friend was admitted to hospital for insertion of a drain to remove excess fluid post op) and IVABs for a post op infection.

My point, if it sounds like the nurse is talking brown stuff, consult directly with the doctor, advise him of your assessment findings, the fact that the child gets super distressed with the q4 salbutamol and request that he makes the order PRN

What's weird is, the doctor was realllly on board with q 4 hr albuterol at the start of our phone conversation. Kept talking about the constant reflux causing mucous production in the upper airway and how the albuterol was going to help clear up the mucous.

Ummm... the albuterol isn't going to make the mucous disappear. If a person is experiencing bronchospasm, adventitious breath sounds like wheezing, difficulty breathing, and therefore can't clear the mucous, yes, let's absolutely get the albuterol. But nobody has been noticing wheezing or respiratory distress in this baby at daycare, including me, and if there's just mucous in the airway, the albuterol's not going to magically dry it up if he's moving air well and coughing and clearing.

I didn't point that out to the doc, but what did win my case was when I said the family wasn't even doing q 4 hr treatments and the kid was somehow alive and thriving on, say, q 8 hr treatments. I guess they had more than one provider believing that the baby was getting q 4 hr albuterol and was still in the condition he was in, which like others have pointed out, if it's that bad, get a controller med! Steroids or something, not just rescue nebs all the time. According to my staff, though, they had reports of the baby sleeping all night without getting a treatment. I pointed out some other things too, but if it weren't for that tidbit of info., that doc was really going to make us do q 4 hr albuterol, just like her nurse said to me.

[inthecosmos, BSN, MSN, RN, APRN]

What's weird is, the doctor was realllly on board with q 4 hr albuterol at the start of our phone conversation. Kept talking about the constant reflux causing mucous production in the upper airway and how the albuterol was going to help clear up the mucous.

Ummm... the albuterol isn't going to make the mucous disappear. If a person is experiencing bronchospasm, adventitious breath sounds like wheezing, difficulty breathing, and therefore can't clear the mucous, yes, let's absolutely get the albuterol. But nobody has been noticing wheezing or respiratory distress in this baby at daycare, including me, and if there's just mucous in the airway, the albuterol's not going to magically dry it up if he's moving air well and coughing and clearing.

I didn't point that out to the doc, but what did win my case was when I said the family wasn't even doing q 4 hr treatments and the kid was somehow alive and thriving on, say, q 8 hr treatments. I guess they had more than one provider believing that the baby was getting q 4 hr albuterol and was still in the condition he was in, which like others have pointed out, if it's that bad, get a controller med! Steroids or something, not just rescue nebs all the time. According to my staff, though, they had reports of the baby sleeping all night without getting a treatment. I pointed out some other things too, but if it weren't for that tidbit of info., that doc was really going to make us do q 4 hr albuterol, just like her nurse said to me.

Why not order something like guafenisen?

[ruby_jane, BSN, RN]

Why not order something like guafenisen?

Shoot....if it's the reflux, why not get that under control?

This is such an interesting thread!! Urbanhealth, you did well!!

[TriciaJ, RN]

Shoot....if it's the reflux, why not get that under control?

This is such an interesting thread!! Urbanhealth, you did well!!

I agree. Reading this thread I kept thinking how lucky for that baby to have OP looking out for him/her.

[JKL33]

Ummm... the albuterol isn't going to make the mucous disappear. If a person is experiencing bronchospasm, adventitious breath sounds like wheezing, difficulty breathing, and therefore can't clear the mucous, yes, let's absolutely get the albuterol. But nobody has been noticing wheezing or respiratory distress in this baby at daycare, including me, and if there's just mucous in the airway, the albuterol's not going to magically dry it up if he's moving air well and coughing and clearing.

Since albuterol is a known smooth muscle relaxant, it is very possible it has been making the reflux situation worse through relaxation of the esophageal sphincter....although the situation is admittedly complicated because they probably started the albuterol to try to help with the pulmonary irritation and asthma-like symptoms they believed were being caused by the reflux (which may indeed have been the case).

As a side note - - is it just me or does it seem like the asthma label/dx is applied fairly quickly/broadly? With years-long (unnecessary) consequences sometimes?

Anyway - - good work.

[KarenMS]

What about chest PT or cough assist?

[OldDude]

...As a side note - - is it just me or does it seem like the asthma label/dx is applied fairly quickly/broadly? With years-long (unnecessary) consequences sometimes?...

OMG! YES, I see that all the time on the elementary level; especially EIB. Drives me crazy because once the kid has has been brainwashed into thinking they can't go to PE without using their inhaler, it's over-dependency is set. However that same kid has no issues with going to recess without pretreating and puts forth 10 times the physical exertion as in PE. Abhhhhhh! And yes, the diagnosis arises from a single office visit. Ugh

[ruby_jane, BSN, RN]

OMG! YES, I see that all the time on the elementary level; especially EIB. Drives me crazy because once the kid has has been brainwashed into thinking they can't go to PE without using their inhaler, it's over-dependency is set. However that same kid has no issues with going to recess without pretreating and puts forth 10 times the physical exertion as in PE. Abhhhhhh! And yes, the diagnosis arises from a single office visit. Ugh

And the kid can't tell the difference between "my chest is tight because I'm wheezing" and "I'm out of breath because I'm deconditioned."

[Qing]

I agree with the others. You need clarification from the doctor about what the plan is exactly and why. The orders will make sense and will be clear on what should be happening then.