Uncontrolled asthma, parents won't pick up- what to do?

[great_lakes_expat]

Hi everyone! I am a long time "lurker," first time poster :-)

I'm a school nurse in a big, urban, public elementary school. I have a lot of kids with very uncontrolled asthma. I'm looking for guidance as to what to do when I give a child their inhaler, but they're still wheezing. Not in distress, and only audible through my stethoscope. But the wheeze is there. I can only give whatever my order says (usually, 2 puffs every 4 hours).

I think that these kids should go home, and ideally to their doctor, if the albuterol is not working. I tell them to call the doctor for instructions- doctor can have them come in, or give them home care instructions. Many parents are receptive to this. But some are not.

All week I've been dealing with a kid like this, and a parent who won't pick up and hasn't contacted the doctor. I'll give him his inhaler, and he'll still be wheezing. It's not bad enough to call an ambulance, and my principal basically told me she couldn't force the parent to come in, and that I should monitor him and call 911 if he goes into distress. This is a new school for me, and I don't really know this family yet. So I don't want to jump to calling child services.

Naturally, it makes me very uncomfortable to have this kid walking around wheezing all day. What do you do in these situations? What do you recommend?

I appreciate y'all's thoughts and guidance! I'm a newer school nurse (this is my second year) and these situations are tricky.

[ruby_jane, BSN, RN]

Unfortunately, until the asthma episode rises to the level of "BBS wheezing and rales noted, all lung fields, student positioning for comfort by leaning over, lips blue, student cannot make four-word sentences, RR 33 and shallow, PSO2 88%" - I think you're stuck monitoring. Because....you don't want to be that nurse, the one who let the kid with the asthma exacerbation go back to class.

Meantime you have 10 other kids in the office, and the student is missing content. Unless the kid is able to go back to class? Little dudes have amazing compensatory mechanisms but they fall of the edge fast.

Is there a doctor for you to contact? Meaning, the doc who signed the orders for albuterol? I would be tempted to do so to see if they can run some intervention or give mom a nebulizer treatment or preventive medication or something.

How much of the day is the student missing? In the past I've approached the administrators in that way - the kid is physically at school but missing content so s/he might actually absence fail a class. I'm a high school nurse so that matters.

It is (sadly) not uncommon for asthma treatment to only include ProAir or other albuterol short-acting inhalers. The kid you describe needs a full prevention regimen. If parents are not motivated to do so or are unable to afford it, that probably needs to be assessed, too.

Good luck!

[OldDude]

We've talked about CPS in many threads. In a case like this, after your documentation trail is in order, and still no change, I would call CPS. In some cases that isn't a bad thing in that it wakes the parent up to resources they might not have been aware of. But first, have you contacted the prescriber of the inhaler to get an asthma action plan, you know like, 4 to 6 puffs every 20 minutes or something like that? There is no HIPPA or FERPA prohibition for you and the child's doctor to communicate about the kid's medical care at school.

[JenTheSchoolRN, BSN, RN]

We've talked about CPS in many threads. In a case like this, after your documentation trail is in order, and still no change, I would call CPS. In some cases that isn't a bad thing in that it wakes the parent up to resources they might not have been aware of. But first, have you contacted the prescriber of the inhaler to get an asthma action plan, you know like, 4 to 6 puffs every 20 minutes or something like that? There is no HIPPA or FERPA prohibition for you and the child's doctor to communicate about the kid's medical care at school.

Yep, I'd also look into contacting the student's doctor. I would first talk to the parents to say I'm doing this. Some parents are so relieved for the help, to be honest - some just hate, hate calling a doctor's office.

This student may need neb orders at school (well, that and perhaps some preventive meds). I have a few students with this plan as part their asthma action plan, even ones taking preventive meds. Inhaler is used, wheezing continues/symptoms are unresolved, but a neb helps a ton! They miss one class with me for a neb, but are typically able to return to class after, cutting down on lost instruction time. Of course, I do not have my own machine, so student/parent needs to provide with the orders, but with the doctor on board, it becomes an easier process.

[WineRN]

How much of the day is the student missing? In the past I've approached the administrators in that way - the kid is physically at school but missing content so s/he might actually absence fail a class. I'm a high school nurse so that matters.

Our SNAP program has a report where I can show how many minutes a student has spent with me for a given length of time. I had a little one at the end of last school year that was diagnosed asthma and using her mother's inhaler and emergency neb treatments in my office every other day.

No one at school took me seriously until I ran this report and showed the teacher and Principal just how long the student was in my office that week.

[SaltineQueen]

There is no HIPPA or FERPA prohibition for you and the child's doctor to communicate about the kid's medical care at school.

Even so, I've never had an office willing to talk to me without an ROI. :/

[OyWithThePoodles, RN]

Even so, I've never had an office willing to talk to me without an ROI. :/

Most offices I call are good about responding and helping if they've written for a medication. I do have one hospital that I sent our ROI to and they sent it back saying it wasn't good enough and I had to fill out one of their forms.

Personally, I would call the prescribing doctor and ask for an asthma action plan, and specifically ask what they want me to do when the child is still wheezing/coughing after an inhaler treatment.

[NurseBeans, BSN, RN, EMT-B]

I would maybe make it clear to the parent what will happen if the asthma gets to that point, where you have to call 911.

You'll be calling 911 and the parent will be meeting their child in the ER.

Now, would they rather control the asthma or let it control them?

[great_lakes_expat]

Hi all-

Thanks so much for your advice! I think that talking to the doctor, and asking for an action plan with more specific inhaler/neb orders, is a great idea. I was able to track down mom at dismissal on Friday, and she signed the consent for me to talk to the doctor. She also said she got him a doctor's appointment after school on Monday, so we'll see. I think I'll hold off calling CPS until I have a better understanding of how this family functions.

But just to clarify: you would not allow a child to walk around the school with a wheeze, even if it is mild and only audible with a stethoscope?

My admin looked at me like I was crazy, and insisted that he "looked fine" and should be in class. I explained that his body was compensating for now and that he could get worse at any time. It doesn't help that this particular kid is known for being less than truthful, and so both admin and his mother think that the kid is "playing" me to get out of class. It's true that he's not always honest, but my stethoscope does not lie. It's like the "little boy who cried wolf!"

Thanks everyone for your input- I'm glad I found this board!