“She’s going home” Narrative:

TL (Victoria): “Next up we have room 9B, Jessie Corman; she is a 14 year old admitted yesterday through ER with asthma exacerbation”.

Resident (Dr. Smith): “Yes, Jessie is to be going home today. I admitted her to the floor yesterday just for overnight observation”.

RN (Ashley): “I am not sure she is ready to go home. She is still on oxygen and has an oxygen saturation around 90 - 93%”.

Resident (Dr. Smith): “She was pretty stable yesterday when I saw her in ER. I think she’ll be good to go. We will try her without the oxygen and see how she does”.

TL (Victoria): “We need this bed. We have 3 other kiddies in ER waiting for a bed. Even if it’s a late discharge we can try her without her oxygen and discharge her later this afternoon”.

RN (Ashley): “I’m not sure she is ready for discharge. She has had some coughing spells overnight and when the night nurse tried to wean her down to 0.5 litres of oxygen her O2 saturation dropped down to 90%. I haven’t listened to her lungs yet this morning, she’s still sleeping, but the night nurse indicated she has some wheezing and subcostal in-drawing”.

Resident (Dr. Smith): “I’ll have a listen to her chest. She’s stable and I am sure she’s good to go”.

RN (Ashley): in a side dialogue with TL

“Victoria….I really don’t think Jessie is ready to go home. I admitted her yesterday and she seems to lack a lot of knowledge about her asthma, medications and treatment plan. I really think she would benefit from another 24 hours here. She is still needing oxygen and a lot of health teaching.”

Learning Aims

1. Understand the etiology and triggers for childhood asthma

2. Explore the various types of treatments and care for children who have asthma

3. Understand the role of nurses in patient advocacy

4. To develop asthma teaching plan for the adolescent.

Pharmacology: bronchiodilators, glucocorticoids, Anticholinergics

Readings - What are the take home messages of these readings?

Canadian Thoracic Society. (2012). Canadian respiratory guidelines. http://www.respiratoryguidelines.ca/canadian-thoracic-society-asthma-management-continuum-%E2%80%93-2010-consensus-summary-for-children-six-year:

Can Respir J Vol 17 No 1 January/February 201015

Canadian Thoracic Society Asthma Management

Continuum – 2010 Consensus Summary for children six years of age and over, and adults

Canadian Thoracic Society Asthma Management Continuum

· Purpose of the study was to integrate new evidence into asthma management in both pediatric and adult patients

· Foundation of asthma management begins with establishing an accurate diagnosis – using medical history and measuring lung function (spirometry, peak expiratory flow variability and positive challenge test)

· Then look into environmental control, education and a written action plan for patient and caregiver

· Have a fast-acting bronchodilator on demand for acute symptoms (fast acting beta-2 agonists

· Adults – controller therapy

- Low dose inhaled corticosteroid is the first-line controller therapy

- When asthma is not controlled with corticosteroid therapy alone, long-acting beta 2 agonists is added

- Leukotriene receptor agonists can be used as second-line mono-therapy or as an add-on

- Anti-immunoglobulin E therapy may be used in those with difficultly controlling allergic asthma despite high dose ICS and one other controller

· Pediatric – controller therapy

- Low dose inhaled corticosteroid is the first-line controller therapy

- When asthma is not controlled with low dose ICS then the dose is increased (moderate dose)

- Leukotriene receptor agonists can be used as second-line mono-therapy or as an add-on

- In those 12 years and older anti-immunoglobulin E therapy may be used in those with difficultly controlling allergic asthma despite high dose ICS and one other controller

Registered Nurses’ Association of Ontario. (2004). Promoting asthma control in children. (pg 21-55) Retrieved from http://rnao.ca/bpg/guidelines/promoting-asthma-control-children

RNAO – Promoting Asthma Control in Children

Key Points

· Asthma is a chronic inflammatory disorder of the airways

· Typical symptoms include shortness of breath, chest tightness, wheezing, and/or coughing (especially night time cough)

· The severity of an asthma episode can range from mild to life-threatening and last from minutes to days

· Airflow limitation in asthma is reversible

· The goal of asthma management is to control or prevent inflammation, and to provide quick relief of symptoms by relaxing the muscles of the airway

· The most common asthma trigger in children is viral infection

· Common asthma triggers include irritants and allergens

· An individual’s triggers may change over time

· Allergic rhinitis, sinusitis or gastroesophageal reflux may aggravate asthma

· Most individuals with asthma accept poorly controlled asthma as normal or do not recognize that their asthma is out of control

· Many physicians are not aware when their patients’ asthma is out of control

· Relievers:

- A reliever should be used on an as needed basis for relief of symptoms

- Best represented by short-acting ß2-agonists

- Act by relaxing the smooth muscle surrounding the airways

- Provide quick relief (within 1-2 minutes)

- Using 4 or more doses (2 puffs/dose) per week (excluding pre-exercise) is an indicator of poor control

· Controllers:

- Inhaled corticosteroids are the main treatment for control of asthma

- Other medications are used as adjuncts when control is not achieved with an adequate dose of inhaled corticosteroids

- Controllers must be taken regularly long-term to prevent or decrease inflammation and edema of the airways

- Slow onset of action

- The management goal for children should always be the lowest dose of inhaled corticosteroids necessary to control symptoms, therefore medication dose needs to be assessed regularly and reduced or discontinued when appropriate

· All children, of any age, should use a spacer device to deliver metered dose inhaled medication

· Ask for a demonstration of technique at each patient contact

· Ensure the most appropriate device is used for each child. Children should use a spacer with a mouth piece as soon as they are developmentally able and can breathe though their mouth without breathing through the nose (usually at 4 to 5 years of age)

· Children on oral or inhaled corticosteroids should have their height and weight documented at each visit to trend over time

· Work with the family to create a management plan that is as simple as possible and that fits the lifestyle of the family

· Assess for drug plan/drug coverage

· Determine whether the family has resources to obtain the delivery device or suggest a less costly alternative (some insurance companies do not cover the cost of delivery devices)

· Education is a key strategy to help children/families gain the motivation, skill and confidence to control asthma

- A team approach to education should be used

- Education should be:

o Tailored to the individual

o Developmentally appropriate

o Appropriate for the setting

o Sensitive to cultural beliefs/values

- A variety of interventions and educational strategies should be used

- Education should utilize a behavioural approach and should emphasize increased knowledge in order to build and maintain asthma self-management skills

· Every child with asthma should have a written asthma action plan

· Action plans have been shown to improve certain outcome measures

· PEF monitoring can be used in most children over the age of 6, however PEF is effort dependent with potential for incorrect readings related to poor technique, misinterpretation, or device failure

NCLEX questions on asthma

- https://www.khanacademy.org/test-prep/nclex-rn/nclex-practice-questions/nclex-rn-questions/e/nclex-rn-questions-on-asthma-3

Additional;

- https://www.khanacademy.org/test-prep/nclex-rn/nclex-practice-questions/nclex-rn-questions/e/nclex-rn-questions-on-asthma-1

The ways of knowing and application to this scenario

Discuss your research

- Understand the role of nurses in patient advocacy (Kate and Gabriella)

o How does it apply in this scenario?

- To develop asthma teaching plan for the adolescent (Michele and Dawn)

Nursing Theory Tutorial

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She's Going Home