Uncontrolled asthma.

[SchoolNurse91, BSN, RN]

I have a student who is always wheezing. I could listen to his lungs at any time of the day and there would be wheezing. This student can take every the inhaler every 4 hours. Today, the student needed his inhaler less than 2.5 hours after his first dose. The doctor is aware on how uncontrolled the asthma. Avg spO2 is around 94-95%.

I closely monitored the child until mom arrived to give the inhaler. She was here in less than 5 minutes.

What happens if you can't reach a parent? Obviously if there was serious distress I would give the inhaler early and then call 911.

Do I just monitor and wait for the situation to become an emergency? I feel backed into a corner.

[Flare, ASN, BSN]

Honestly, I would make sure that your admin knows about this situation. There is only so much that we can do with a prn albuterol inhaler. In addition, I would call the dr myself and see if you could have a little powwow. The whole picture may not be getting clearly viewed with the parent acting as a go-between. I may even call upon our district physician for advice. Perhaps this child needs a maintenance medication or different medication maintenance med. Also, is there an order for the albuterol to be given via nebulizer? That may have a better effect. And CHART CHART CHART.

[tining, BSN, RN]

Asthma Action Plan is better than just the doctor's orders.

[SchoolNurse91, BSN, RN]

51 minutes ago, Flare said:

Honestly, I would make sure that your admin knows about this situation. There is only so much that we can do with a prn albuterol inhaler. In addition, I would call the dr myself and see if you could have a little powwow. The whole picture may not be getting clearly viewed with the parent acting as a go-between. I may even call upon our district physician for advice. Perhaps this child needs a maintenance medication or different medication maintenance med. Also, is there an order for the albuterol to be given via nebulizer? That may have a better effect. And CHART CHART CHART.

I'm not sure what admin would do? Is there something they can do to assist?

I spoke with the MA at the office today. Per the MA, the doctor is aware of the issues. Mom is showing up to all appointments. He is on several preventative medications. The order we have is inhaler only.

We do not have a physician on staff.

44 minutes ago, tining said:

Asthma Action Plan is better than just the doctor's orders.

We have one. The only thing the doctor put on there is the albuterol every 4 hours.

[tining, BSN, RN]

That's too bad, he really could have increased the puffs and decreased time between for yellow or red zone. Is this a specialist or pediatrician. Might need to see a pulmonologist.

[CanIcallmymom, BSN, RN]

29 minutes ago, kelleyk1991 said:

I'm not sure what admin would do? Is there something they can do to assist?

I spoke with the MA at the office today. Per the MA, the doctor is aware of the issues. Mom is showing up to all appointments. He is on several preventative medications. The order we have is inhaler only.

We do not have a physician on staff.

We have one. The only thing the doctor put on there is the albuterol every 4 hours.

I have a student that is so similar!!! It took me sending them out via EMS to have some changes to their orders (no Asthma Action Plan per se, but I have very clear orders now from their doc). I now have orders that state that I can give up to 4 puffs for severe episodes x 3 20 minutes apart with a new inhaler (levalbuterol). They also provided me with albuterol neb orders with the same-I can give 3 doses 20 minutes apart for severe symptoms. Student tells me they added ipratropium to the orders for her nebs, but I haven't received these orders yet.

[ruby_jane, BSN, RN]

39 minutes ago, kelleyk1991 said:

I'm not sure what admin would do? Is there something they can do to assist?

I spoke with the MA at the office today. Per the MA, the doctor is aware of the issues. Mom is showing up to all appointments. He is on several preventative medications. The order we have is inhaler only.

We do not have a physician on staff.

We have one. The only thing the doctor put on there is the albuterol every 4 hours.

Multidisciplinary team effort:

Is this interfering substantially with his classroom work? Yes - speak to teacher/counselor. Maybe there needs to be a 504? Not sure if that would help. Someone in the school besides you should be aware of these issues, though.

The MA indicates "several preventative medications" and yet this kid is rolling off his tracks. Maybe a sitdown with parent to discuss when/how/if medications are being used? Yes, this is the doc's job but at least one time a year I find out that the preventive meds are "too expensive" (no judgment there) and the parent will use the sample but not get the rX. Or it is possible that everyone is doing everything right and the kid is just extremely reactive.

If that's all you have - and the situation does not resolve with the two puffs - EMS. Because in the ER they'd neb him for as long as it took. It is possible if it was me and the student was of an age to self-administer AND the sats/wheezing/tightness had not improved and the struggle was real that I'd hand the inhaler to the kid....while waiting for EMS.

[SchoolNurse91, BSN, RN]

On 2/18/2020 at 4:17 PM, tining said:

That's too bad, he really could have increased the puffs and decreased time between for yellow or red zone. Is this a specialist or pediatrician. Might need to see a pulmonologist.

I agree. It is a family medicine doctor. Mom states she is waiting to see a specialist.

On 2/18/2020 at 4:34 PM, ruby_jane said:

Multidisciplinary team effort:

Is this interfering substantially with his classroom work? Yes - speak to teacher/counselor. Maybe there needs to be a 504? Not sure if that would help. Someone in the school besides you should be aware of these issues, though.

The MA indicates "several preventative medications" and yet this kid is rolling off his tracks. Maybe a sitdown with parent to discuss when/how/if medications are being used? Yes, this is the doc's job but at least one time a year I find out that the preventive meds are "too expensive" (no judgment there) and the parent will use the sample but not get the rX. Or it is possible that everyone is doing everything right and the kid is just extremely reactive.

If that's all you have - and the situation does not resolve with the two puffs - EMS. Because in the ER they'd neb him for as long as it took. It is possible if it was me and the student was of an age to self-administer AND the sats/wheezing/tightness had not improved and the struggle was real that I'd hand the inhaler to the kid....while waiting for EMS.

The entire office staff is aware of the issue. I am only at the school 1-2 days per week. They're usually the ones taking care of him.

The student is on Medicaid, so his medications are covered 100%. Mom tells she is frustrated because she feels as if the doctor is not doing what she should be. She is waiting to get into a specialist.

I have given the medication 15 minutes early, with parent permission. But he needs it more frequently now. I do not feel it is appropriate to give a medication 1-2 hours early without a new order.

[ruby_jane, BSN, RN]

On 2/18/2020 at 4:40 PM, kelleyk1991 said:

I agree. It is a family medicine doctor. Mom states she is waiting to see a specialist.

The entire office staff is aware of the issue. I am only at the school 1-2 days per week. They're usually the ones taking care of him.

The student is on Medicaid, so his medications are covered 100%. Mom tells she is frustrated because she feels as if the doctor is not doing what she should be. She is waiting to get into a specialist.

I have given the medication 15 minutes early, with parent permission. But he needs it more frequently now. I do not feel it is appropriate to give a medication 1-2 hours early without a new order.

YOWZA.

I agree with you - I wouldn't give the med myself without a new order unless I thought it was life or death....

[SchoolNurse91, BSN, RN]

Just now, ruby_jane said:

YOWZA.

I agree with you - I wouldn't give the med myself without a new order unless I thought it was life or death....

That is my thought as well. I feel awful for the student but my hands are tied. I'm the only RN in the district and my supervisor is a special education teacher. I don't have anyone to bounce ideas off of. I appreciate the input.

[ruby_jane, BSN, RN]

1 minute ago, kelleyk1991 said:

That is my thought as well. I feel awful for the student but my hands are tied. I'm the only RN in the district and my supervisor is a special education teacher. I don't have anyone to bounce ideas off of. I appreciate the input.

YOWZA!!!

We're all here for the struggle, friend. I am suddenly grateful for my current caseload.

[Flare, ASN, BSN]

16 hours ago, kelleyk1991 said:

I'm not sure what admin would do? Is there something they can do to assist?

I spoke with the MA at the office today. Per the MA, the doctor is aware of the issues. Mom is showing up to all appointments. He is on several preventative medications. The order we have is inhaler only.

We do not have a physician on staff.

We have one. The only thing the doctor put on there is the albuterol every 4 hours.

Getting the admin involved is more of a CYA move on your part. They can't do anything to make this child better, but if the child should deteriorate under your care, holding yourself to your orders as you should, this acts as a pre-emptive strike. Heaven forbid that this child deteriorates to the point that there is a status asthmaticus situation where 911 is obviously called, but the child still has a complication (or ems takes long.. . etc). It's about trying to keep your name out of the headlines.