Occasionally I'll get one of my asthma students complaining about an asthma attack, but her lungs are nice and clear - no wheezing or diminished lung sounds. Vital signs are normal; no signs of respiratory distress but is open mouthed "wheezing" and heavily breathing, but I don't here anything amiss in her lungs. This girl has come with this twice, and has an inhaler here but she says it's not helping. Answers "yes" or "no" to questions. I'm not sure if she's being a drama queen, but I'm highly suspicious of this behavior . Each time I've called parent and reported my findings, and they've come to pick her up. Is it possible I'm missing something here? I've seen genuine asthma attacks, and they are indeed scary. Naturally, I don't want to overlook anything with her, and I always err on the side of caution and call parent...
Specializes in mommy/baby, home health, school nurse.
So yesterday I had one of the kids come in c/o SOB. Does she have asthma, yup. Is her inhaler at school, nope. I did an assessment, her lungs were clear, pulse and resp were WNL, she was talking to me without any difficulty, color was better than mine. I had to call grandmom, 30 - 45 minutes away. Do I think she was faking it, yes, but I wasn't going to not do what I could to get her inhaler. Oh, and did anyone leave me one, nope.
I've has the same thing happen in more than one instance. If I truly question the validity I get the parents involved. I also make sure the child knows it's not safe to take meds if they don't need them. This always took care of any problems with the fakers. That being said, there are asthmatics that can feel symptoms coming on such as chest tightness before they show other symptoms. I'd rather them have their inhaler before it progresses to wheezing. My own daughter feels tightness and shortness of breath without wheezing. You're right to err on the side of caution.
Specializes in TCU, Post-surgical, Infection Prevention.
I'm sorry that you are not satisfied with the nurses in your daughter's school, but I dont think that justifies jumping on this poster who specifically asked for information and advice because she wants to "err on the side of caution" in regards to her students.
No worries, I was obviously dealing with a RN with limited experience with breathing problems. Additionally, that was years ago when I was a young mother, dear. All is well.
If a patient is "wheezing" that is a later sign. Children should have been taught to gage how they are feeling and they should also have been taught to keep journals especially of their PEFRs. Did anyone here even ask about PEFR or check if there was a change in their maintenance medications such as for allergies or LABAs which might be given in the morning at home? Did anybody ask if there is a change in their living environment like 3 pack a day cigarette Grandma visiting or new pets? When was the last time a PFT was done? Was there a bronchodilator response? When PFTs are done, rarely is the patient actively wheezing but you can see >than 15% response in the flow volume curve post bronchodilator. Being a patient advocate should mean teaching or reinforcing the skills other practitioners may have taught them. It should not mean making the child feel quilt or ashamed for needing a bronchodilator. If you really think the child is faking, don't "sound" like you don't believe them. Ask them questions to show them how to make informed decisions about their health care and give them the tools to quantify and qualify their own care.
The fact that kids have to come to the nurse's office and beg for an inhaler just horrifies me. The fact that in both the US and Canada, both supposedly educated countries, this still happens.
This happened just a year ago. There are unfortunately several other cases like this right here in the US.
Time for more education. I recommend all who are involved with asthmatic children to take the Asthma Educator course even if you don't get the national certification.
I read through this thread pretty quickly and I didn't see a mention of doing a peak flow. We have a generalized asthma information form we send to parents to fill out. It has a spot for them to write in their peak flow. A lot of parents don't fill it out but some do.
Peak flows are calculated on height/size of the child and age. It measures the airflow through the bronchi and thus the degree of obstruction in the airways. They have to be taught how to use it, of course if they have never done one.
It's a relatively easy thing to do to help you gauge the severity of the "asthma attack."
I do peak flows in my office. In fact, I'm the one that usually recommends to parents/students that need to monitor peak flows and have student bring in his/her peak flow meter. It also gives me a good reading of something I might not pick up on.
I'm a big fan of kids self-carrying and luckily, my school allows that with signed parental permission. I work with middle and high school students and the middle school is all the way on the other side of the building.
Following up on new triggers is key; for example, one of asthma kids started having more attacks this fall than ever before, let to several absences. I expressed concern to the parent as she was new to this school building; child was allergy tested and it revealed a dust allergy.
But I never not let a child have his/her inhaler. However, I can understand wondering if it is always needed if the child requests to use it 4x times in one school day yet appears after assessment to be without respiratory distress. For this, peak flow monitoring helps beyond a lung assessment for me; it is also a great teaching tool about how to stay on top of the symptoms/management and write an in school IHCP.
Of course, I am both a new nurse and new school nurse, so I always feel like I need to learn more about asthma (and diabetes, but different matter). Luckily, my states does offer some CEUs that I hope to complete throughout the school year :).
First, I take great offense to your tone. I don't think it was warranted, or necessary.
"Did anyone here even ask about PEFR or check if there was a change in their maintenance medications such as for allergies or LABAs which might be given in the morning at home? Did anybody ask if there is a change in their living environment like 3 pack a day cigarette Grandma visiting or new pets? When was the last time a PFT was done? Was there a bronchodilator response?" You do realize this is an elementary school, right? Further, the parent has never, and refuses to provide us either a doctor's note allowing her to use the inhaler, or an Asthma Action Plan, despite the many, many documents and phone calls being sent home by myself and the School District.
"Being a patient advocate should mean teaching or reinforcing the skills other practitioners may have taught them". I have no idea, nor do I have any way of ascertaining, what other practitioners have taught her. In my school, I was trained in, and co-taught 4th and 5th graders via the Healthy Kids program with the American Lung Association.
This one really gets me . "It should not mean making the child feel guilt (not quilt) or ashamed for needing a bronchodilator". Where did that come from? Where in my post does it even hint that was what I did? You have no clue what I did, yet you are making judgments on something you know nothing of. Or were you in the clinic with me that day observing what happened? I didn't "sound" like I thought she was faking with her, rather the opposite. She had her inhaler on her!!! No begging needed. She'd given herself the inhaler, and I sat with her and did pursed-lip breathing and relaxation techniques until Mom got there. Oh, that's right, you were there watching, right? And "come up" to my office? No, I have a rule I go to where the child is, which is what I did. I went to her classroom, as I always have. Oh, I forgot, you were there so you saw everything.....
For the others who suggested peak flow meters, the doctors have the option of giving an order for the child bring one in. Despite numerous requests, the mother has repeatedly refused to bring us a doctor's note or an Asthma Action Plan.
I'm not sure where anyone got the idea that the child was refused her inhaler. Again, she had her own inhaler on her person and used it!
It seem the postings on Allnurses are becoming more and more hostile. Forgive my sarcasm above, but I mistakenly thought this was forum to go for questions and get help, not get beaten up on. Remember, the title of my post was "A silly question..."
I'm done with Allnurses. I'm sticking to the Break Room from now on. At least people have manners there.
First, I take great offense to your tone. I don't think it was warranted, or necessary.
"Did anyone here even ask about PEFR or check if there was a change in their maintenance medications such as for allergies or LABAs which might be given in the morning at home? Did anybody ask if there is a change in their living environment like 3 pack a day cigarette Grandma visiting or new pets? When was the last time a PFT was done? Was there a bronchodilator response?" You do realize this is an elementary school, right? Further, the parent has never, and refuses to provide us either a doctor's note allowing her to use the inhaler, or an Asthma Action Plan, despite the many, many documents and phone calls being sent home by myself and the School District.
"Being a patient advocate should mean teaching or reinforcing the skills other practitioners may have taught them". I have no idea, nor do I have any way of ascertaining, what other practitioners have taught her. In my school, I was trained in, and co-taught 4th and 5th graders via the Healthy Kids program with the American Lung Association.
This one really gets me . "It should not mean making the child feel guilt (not quilt) or ashamed for needing a bronchodilator". Where did that come from? Where in my post does it even hint that was what I did? You have no clue what I did, yet you are making judgments on something you know nothing of. Or were you in the clinic with me that day observing what happened? I didn't "sound" like I thought she was faking with her, rather the opposite. She had her inhaler on her!!! No begging needed. She'd given herself the inhaler, and I sat with her and did pursed-lip breathing and relaxation techniques until Mom got there. Oh, that's right, you were there watching, right? And "come up" to my office? No, I have a rule I go to where the child is, which is what I did. I went to her classroom, as I always have. Oh, I forgot, you were there so you saw everything.....
For the others who suggested peak flow meters, the doctors have the option of giving an order for the child bring one in. Despite numerous requests, the mother has repeatedly refused to bring us a doctor's note or an Asthma Action Plan.
I'm not sure where anyone got the idea that the child was refused her inhaler. Again, she had her own inhaler on her person and used it!
I don't care if you don't like the tone. ASTHMA IS A KILLER. The fact that there are still kids dying in the school systems from asthma makes this a serious issue. There was nothing mentioned about the assessments in the posts except for breath sounds. You also did not state the doctor would not write "an order for a PEFR. A PEFR should not require an order and is often a standard of care in most hospitals and clinics. Ask the child if they have a PEF device.
I could not assume anything from what is written in your initial post. Your post was vague and offered almost nothing for assessment and you asked for input. You did not include any of the info you just posted.
I just wanted to point out there are many other assessment factors besides breath sounds which go into decision making.
We go to great lengths on the Pedi floors, ED and our clinics to teach kids about their asthma. I would hope other hospital systems are trying to do the same. It pains me to read some of these posts and then your "I take great offense" comment. I take great offense that you are assuming to know what everyone else is doing and that all is roses and honey.
Maybe you have never seen a child die from asthma. Maybe you haven't had to intubate an asthmatic child on the floor of a school . It is really sad when the child comes from a school system where the school nurse keeps all inhalers locked up and the child must be in audibly wheezing before an inhaler is given. I have also worked codes at schools during my EMS life where the School Nurse is saying "I didn't think they were that bad because there were no wheezes".
You also can not imagine some of the stuff we hear at an asthma educator class and there are a few school nurses present. So too bad if you are so easily offended by the seriousness of asthma or you want me to honey coat everything to say you totally right. I am an advocate for babies and kids. I also believe in more education for nurses, the kids, the parents and the doctors. Don't get angry at the advocates who want to make a difference in the health of a child. Get angry at the systems (healthcare and school) which often fail these kids.
So yesterday I had one of the kids come in c/o SOB. Does she have asthma yup. Is her inhaler at school, nope. I did an assessment, her lungs were clear, pulse and resp were WNL, she was talking to me without any difficulty, color was better than mine. I had to call grandmom, 30 - 45 minutes away. Do I think she was faking it, yes, but I wasn't going to not do what I could to get her inhaler. Oh, and did anyone leave me one, nope. [/quote']
I have had this same issue although I don't think my student is faking anything. We've been trying to get the parents to bring a rescue-inhaler to school since the beginning of school.
Two weeks ago while parents were out of the country on vacation, he had an asthma attack. Grandma had to bring the inhaler to school but it didn't help much (he had to wait to use it!) so she took him to the doc, where he was put on an antibiotic and a steroid. Parents were again notified that we needed an inhaler. Last week, I got a call at 10 a.m. saying he had come in from the playground where he was playing basketball c/o difficulty breathing. Again, they had to send someone for his inhaler. I got there in 5 minutes and he was drinking some cold water. He had high-pitched exp wheezes. His VS were stable. Resp 22; 96% 02 Sat; HR 73; BP 90/70. BUT he was complaining about his lungs hurting and he was coughing. His parents were out of town but I left them a message saying if he didn't get any better I was taking him to the ER. Of course, he didn't get better. I took him to the ER and the doc was appreciative and told me I did the right thing. He was there for about an hour. The doc did a very thorough work-up. Grandma came in while he was being treated. The doc stated he wanted an inhaler at school, the grandma signed the paperwork, I got an inhaler. (Grandma is legal person when parents are out of town). Started him on Prednisone taper too.
The kiddo came back to school after lunch and was fine the rest of the day. Remember, this was last week.
I heard by chance that the parents came in and complained to the principal that I didn't call everyone on the emergency list and that he was fine because his 02 Sat in the ER was 98%.
So, I'm meeting with them this afternoon. I've spoken with the ER doc, who has my back. I've got all my info - like kids can compensate with VS for a long time when they are truly sick and then crump - every peds nurse will tell you that. We are trained not to trust VS and look at the patient. His lungs went from wheezes to quiet . . ."decreasing wheeze and breath sounds and a "quiet chest" in a child with increasing resp effort may signal imminent respiratory failure".
I think what they are mostly concerned with is the ER visit and the price. Well, if you had let us have in inhaler and we had given it sooner, he may have been fine.
I take NO chances with kids. They are sneaky little devils who look healthy and then die on us.
I appreciate the article about the Canadian young man who died because he didn't get his inhaler in time. I googled more about youth deaths related to asthma and in school and came up with a whole bunch.
I wish I could just do this meeting with myself and the parents but I'm sure the principal will want to be in on it - but she didn't have any medical info to give them about this issue when they met with her and she didn't call me to tell me about it.
. Each time I've called parent and reported my findings, and they've come to pick her up. Is it possible I'm missing something here? I've seen genuine asthma attacks, and they are indeed scary. Naturally, I don't want to overlook anything with her, and I always err on the side of caution and call parent...
. "It should not mean making the child feel guilt (not quilt) or ashamed for needing a bronchodilator". Where did that come from? Where in my post does it even hint that was what I did? You have no clue what I did, yet you are making judgments on something you know nothing of. Or were you in the clinic with me that day observing what happened? I didn't "sound" like I thought she was faking with her, rather the opposite. She had her inhaler on her!!! No begging needed. She'd given herself the inhaler, and I sat with her and did pursed-lip breathing and relaxation techniques until Mom got there. Oh, that's right, you were there watching, right? And "come up" to my office? No, I have a rule I go to where the child is, which is what I did. I went to her classroom, as I always have. Oh, I forgot, you were there so you saw everything.....
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Stitchy's mom
34 Posts
So yesterday I had one of the kids come in c/o SOB. Does she have asthma, yup. Is her inhaler at school, nope. I did an assessment, her lungs were clear, pulse and resp were WNL, she was talking to me without any difficulty, color was better than mine. I had to call grandmom, 30 - 45 minutes away. Do I think she was faking it, yes, but I wasn't going to not do what I could to get her inhaler. Oh, and did anyone leave me one, nope.