AST HMA BE ST PRACT I CE S F OR SCHOOL NURSE S Sc ho o l - - PowerPoint PPT Presentation

AST HMA BE ST PRACT I CE S F OR SCHOOL NURSE S

Sc ho o l Nurse s No ve m b e r 2015

1

BACK GROUND AND CURRE NT ST AT S

Ge ne ra l de finitio ns a nd e xpla na tio ns

2

I nc ide nc e o f Asthma

• Ce nte rs fo r Dise a se Co ntro l (CDC) -
• 1 in 12 a dults ha ve a sthma
• 65% o f the se pe o ple ha ve pe rsiste nt a sthma
• 35% o f the se pe o ple ha ve inte rmitte nt a sthma
• 1 in 11 c hildre n ha ve a sthma
• 60% o f the se c hildre n ha ve pe rsiste nt a sthma
• 40% o f the se c hildre n ha ve inte rmitte nt a sthma
• K

a nsa s ra nks in the to p 8 sta te s in the US fo r hig he st numb e r o f c hildre n with pe rsiste nt a sthma

• 9 pe rso ns die da ily fro m a sthma
• I

n 2009 – 3,388 pe rso ns die d fro m a sthma

• NHL

BI – a sthma is the mo st c o mmo n c hro nic dise a se o f c hildho o d, a ffe c ting 6 millio n c hildre n

3

Asthma Sta ts

• I

n 2013 – numb e r o f misse d sc ho o l da ys re po rte d re la te d to a sthma – 13.8 millio n

• 20 – 25% o f pe rso ns with a sthma o ve ruse the ir “q uic k re lie f me dic a tio ns”

(K a nsa s)*

• Only 40% o f pe rso ns with a sthma use d “lo ng te rm c o ntro l” me dic a tio ns

(K a nsa s)*

• 40% o f c hildre n a nd 47% o f a dults ha ve unc o ntro lle d a sthma (K

a nsa s)*

• 22% o f pe rso ns with a sthma smo ke [16% witho ut a sthma smo ke ] (K

a nsa s)*

• 30% o f c hildre n a nd 33% o f a dults with a sthma a re o b e se (K

a nsa s)*

• 97% o f c hildre n a nd 85% o f a dults with a sthma ha d insura nc e c o ve ra g e

(K a nsa s)*

*Na tio na l Ce nte r fo r He a lth Sta tistic s, Divisio n o f He a lth Inte rvie w Sta tistic s (2012)

4

Wha t is Asthma ?

• Chro nic , o b struc tive , infla mma to ry diso rde r due

to hype r-re spo nsive ne ss o f a irwa y, a irwa y e de ma , a irwa y na rro wing , a nd muc us pro duc tio n.

• Chro nic infla mma to ry diso rde r o f the a irwa ys

tha t re sults in inte rmitte nt a nd re ve rsib le a irflo w

• b struc tio n o f the b ro nc hio le s.

5

I nfla mma tio n

Airwa y Hype r-re spo nsive ne ss Airwa y Ob struc tio n Clinic a l Sympto ms

6

Asthma T ria d

• Bro nc ho c o nstric tio n
• Airwa y hype r-re spo nsive ne ss
• Airwa y e de ma (muc us a nd e de ma )
• Re mo de ling

7

Re po nse s

• I

mme dia te re spo nse

• Mast cells activate IgE → release of mediators (histamines, leukotrienes, and

prostaglandins)→ bronchospasms shortly after exposure. Resolves in 1-2

ho urs.

• De la ye d re spo nse
• Che mic a l me dia to rs a ttra c t immune syste m c e lls (e o sino phils, b a so phils, a nd

neutrophils) → infiltrate and cause release of additional inflammatory material → damage to smooth muscle cells causing further edema and

muc us o b struc tio n o f sma ll a irwa ys.

8

Re spo nse s

• Bro nc ho c o nstric tio n
• Several hours in length → can reoccur
• Airwa y hype r-re spo nsive ne ss
• Ca n la st fo r we e ks o r mo nths
• Blood flow to obstructed alveoli and open alveoli → ventilation-pe rfusio n

mismatch → decreased pO2 → hypoxia

9

Ca use s o f Asthma

• I

nte rpla y o f a ho st o f fa c to rs

• I

nna te immunity

• Ge ne tic s
• E

nviro nme nta l fa c to rs

• Airb o rne a lle rg e ns
• Vira l re spira to ry infe c tio ns
• T
• b a c c o smo ke
• Air po llutio n
• Die t

10

Sympto ms o f Child Asthma

• Childre n typic a lly ha ve mo re c o ug hing

VS whe e zing

• Childre n o fte n pre se nt with nig ht

va ria nt a sthma

• Ve ry yo ung c hildre n ma y ha ve he a d

b o b b ing with b re a thing

• Spiro me try in c hildre n o lde r tha n 5-6

ye a rs ma y b e use d fo r dia g no sis

• Childre n ma y re po rt sympto ms b ut

mo st like ly sympto ms a re o b se rve d a nd he a rd

11

E XPE RT PANE L RE PORT 3 (E PR3)

Na tio na l He a rt L ung a nd Blo o d I nstitute Na tio na l Asthma E duc a tio n a nd Pre ve ntio n Pro g ra m

12

Ma na g ing Asthma L

• ng te rm
• Go a ls:
• I

mpro ve the q ua lity o f life

• Pre ve nt tro ub ling a nd c hro nic sympto ms
• Re q uire infre q ue nt use o f SABA (< 2 time s pe r we e k)
• Ma inta in ne a r no rma l pulmo na ry func tio n
• Ma inta in no rma l a c tivity le ve ls
• Me e t pa tie nt a nd fa mily e xpe c ta tio ns o f sa tisfa c tio n with a sthma c a re
• Pre ve nt re c urre nt e xa c e rb a tio ns o f a sthma to minimize misse d sc ho o l da ys,

E D visits, a nd ho spita liza tio ns

• Pre ve nt lo ss o f lung func tio n; fo r c hildre n – pre ve nt re duc e d lung g ro wth
• Pro vide o ptima l pha rma c o the ra py with minima l o r no r a dve rse e ffe c ts o f

the ra py

13

4 Co mpo ne nts o f Ca re

• 1. Asse ssme nt a nd mo nito ring
• 2. E

duc a tio n fo r a pa rtne rship in c a re

• 3. Co ntro l o f e nviro nme nta l fa c to rs a nd c o mo rb id

c o nditio ns tha t a ffe c t a sthma

• 4. Me dic a tio ns

14

Co mpo ne nt 1: Asse ssing a nd Mo nito ring Asthma Se ve rity a nd Asthma Co ntro l

• Se ve r

ity: inte nsity o f the dise a se pro c e ss

• Contr
• l: de g re e o f c o ntro l
• Re sponsive ne ss: e a se o f c o ntro l a c hie ve d
• Impair

me nt: fre q ue nc y a nd inte nsity o f sympto ms

• Risk: like liho o d o f e xa c e rb a tio n, pro g re ssive de c line , a dve rse

e ffe c ts o f me dic a tio ns. F

• r c hildre n – risk o f re duc e d lung g ro wth

15

Asthma Cla ssific a tio ns

16

Inte r mitte nt Mild Pe r siste nt Mode r ate Pe r siste nt Se ve r e Pe r siste nt

F re q ue nc y o f sympto ms 2x/ we e k >2x/ we e k b ut no t da ily Da ily T hro ug ho ut the da y Nig httime a wa ke ning s 0-4 yrs: 0 Olde r: 1x o r le ss/ mo nth 0-4 ye a rs o ld: 1- 2x/ mo nth Olde r: 3-4x/ mo nth 0-4 yrs o ld: 3-4x/ mo nth Olde r: > 1x/ we e k b ut no t nig htly 0-4 yrs o ld: >1x/ we e k Olde r: o fte n, 7x/ we e k Ac tivity No limita tio ns Mino r limita tio n So me limita tio n E xtre me ly limite d SABA use < 2 d/ we e k 2 d/ we e k o nly Da ily Se ve ra l x/ da y E xa c e rb a tio ns Re q uiring o ra l syste mic c o rtic o ste ro ids No ne – 1x/ ye a r 0-4 yrs: >2x/ yr o r 4 whe e zing e piso de s/ yr la sting 1 da y with risk fa c to rs Olde r: >2x/ yr 0-4 yrs: no impro ve me nt Olde r: >2x/ yr with risk fa c to rs a nd c ha ng e s to F E V1 > 2x/ yr fo r a ll a g e s with risk fa c to rs a nd c ha ng e s to F E V1

Co mpo ne nt 2: E duc a tio n o f a Pa rtne rship in Ca re

• Ope n c o mmunic a tio ns
• Addre ssing c o nc e rns
• De ve lo ping tre a tme nt g o a ls to g e the r
• E

nc o ura g ing se lf-mo nito ring a nd se lf-ma na g e me nt

• Asthma a c tio n pla n
• T

a lking a b o ut a sthma sympto ms a nd pla n a t e ve ry o ppo rtunity

• (PHCP – se le c ting me dic a tio ns tre a tme nts g o a ls to g e the r)

17

Asthma Ac tio n Pla ns

18

 Written Care Guidelines are

very important…

 Define what to do when… daily &

acute

 Define when to be concerned  Define when to seek help

• Obtaining a plan is important for

the school nurse

• Fax form to office for PHCP to

complete and return

• Use of standardized AAPlan form

Pe a k F lo w Me a sure me nts

• Pe rso na l Be st (PB)
• Gre e n 80-100% o f PB
• Ye llo w 50-70% o f PB
• Re d >50%

19

20

21

Co mpo ne nt 3: Co ntro l o f E nviro nme nta l F a c to rs a nd Co mo rb id Co nditio ns tha t Affe c t Asthma

• I

de ntify a lle rg e n a nd po lluta nts o r irrita nt e xpo sure s

• Skin te sting
• HE

PA filte rs

• I

de ntify a nd tre a t c o mo rb id c o nditio ns

• GE

RD

• Ob e sity
• Ob struc tive sle e p a pne a
• Alle rg ie s a nd sinusitis
• Stre ss

22

T rig g e rs in the sc ho o l…

• Cle a ning supplie s
• Smo king a re a s
• Cla ssro o m pe ts
• F
• o ds a t pa rtie s
• F

ra g ra nc e s

• Building re mo de ling , pa inting , ne w c o nstruc tio n, rug s
• Bus a nd pa re nt dro p-o ff ho lding a re a s
• We a the r - b us sto ps, re c e ss, tra ve l b e twe e n b uilding s

23

Co mpo ne nt 4: Me dic a tio ns

• Co rtic o ste ro ids
• Ma st c e ll sta b ilize rs
• I

mmuno mo dula to rs

• L

e uko trie ne mo difie rs

• L
• ng a c ting b e ta 2 a g o nists (L

ABA)

• Sho rt a c ting b e ta 2 a g o nists (SABA)
• Me thylxa nthine s
• Antic ho line rg ic s

24

T re a tme nt b y Ste ps

• Appro pria te tre a tme nt o f a sthma is no t b y

c la ssific a tio n

• T

re a tme nt is b y ste ps – pro g re ssing fro m ste p 1 fo r inte rmitte nt a sthma to ste ps 2-5 fo r pe rsiste nt a sthma

• T

re a tme nt thro ug h ste ps 2-5 is fluid a nd mo ve s in e ithe r dire c tio n b a se d o n c o ntro l a sse ssme nt o f the c hild

• Re q uire s re g ula r visits a nd c ha ng e s in a sthma a c tio n

pla ns

25

Ste pwise Appro a c h to T re a tme nt

0-4 ye a rs o f a g e

Ste p 1 Ste p 2 Ste p 3 Ste p 4 Ste p 5 Ste p 6

I nte rmitte nt Pe rsiste nt

→ → → →

Pre fe rre d SABA prn L

• w-do se

I CS Me d-do se I CS Me d-do se I CS + L ABA o r Mo nte luka st Hig h-do se I CS + L ABA o r Mo nte luka st Hig h-do se I CS + Ora l ste ro ids + L ABA o r Mo nte luka st Alte rna te Cro mo lyn o r Mo nte luka st L ABA o r Mo nte luka st Quic k- re lie f SABA prn SABA prn SABA prn SABA prn SABA prn SABA prn

26

F re q ue nt use o f SABA ma y indic a te the ne e d to ste p-up the ra py

Ste pwise Appro a c h to T re a tme nt

5-11 ye a rs o f a g e

Ste p 1 Ste p 2 Ste p 3 Ste p 4 Ste p 5 Ste p 6

I nte rmitte nt Pe rsiste nt

→ → → →

Pre fe rre d SABA prn L

• w-do se

I CS L

• w-do se

I CS + L ABA, L T RA.

• r

T he o phylline Me d-do se I CS + L ABA Hig h-do se I CS + L ABA Hig h-do se I CS + L ABA + Ora l ste ro ids Alte rna tive Cro mo lyn , L T RA, Ne do c ro mil,

• r

T he o phylline Me d-do se I CS Me d-do se I CS + L T RA o r T he o phylline Hig h-do se I CS + L T RA o r T he o phylline Hig h-do se I CS + L ABA + Ora l ste ro ids Quic k-re lie f SABA prn SABA prn SABA prn SABA prn SABA prn SABA prn

27

Ste pwise Appro a c h to T re a tme nt

> 12 ye a rs a nd a dults

Inte r mitte nt Pe r siste nt

→ → → →

Ste p1 Pre fe rre d: SABA prn Ste p 2 Pre fe rre d: L

• w-do se I

CS Ste p 3 Pre fe rre d: L

• w-do se I

CS + L ABA o r Mo nte luka st Ste p 4 Pre fe rre d: Me d-do se I CS + L ABA Ste p 5 Pre fe rre d: Hig h-do se I CS + L ABA AND Co nside r Oma lizuma b fo r a lle rg y pa tie nts

Ste p 6 Pre fe rre d: Hig h-do se I CS + L ABA +

• ra l ste ro ids

AND c o nside r Oma lizuma b fo r a lle rg y pts

Alte rna te : Cro mo lyn, L T RA, Ne do c ro mil, o r T he o phylline Alte rna te : L

• w-do se I

CS + e ithe r L T RA, T he o phylline ,

• r Zile uto n

Alte rna te : Me d-do se I CS + e ithe r L T RA, T he o phyllin, o r Zile uto n

SABA prn SABA prn SABA prn SABA prn SABA prn SABA prn

28

Co nside r “a lle rg y sho ts” fo r pa tie nts who ha ve a lle rg ic a sthma

ME DI CAT I ONS

T re a tme nt Re c o mme nda tio ns

29

L ABA (L

• ng -a c ting Be ta 2-a g o nists)
• Sa lme te ro l (Se re ve nt)
• F

a mo te ra l

• Dry po wde r inha le rs
• Bro nc ho dila to rs
• Childre n unde r 4 sho uld no t

use

30

Co mb ine d Me dic a tio ns

• F

lutic a so ne / Sa lme te ro l – (Adva ir)

• Bude so nide / F

a mo te ro l - (Symb a c o rt)

• De c re a se s infla mma tio n
• E

nha nc e s b ro nc ho dila tio n o f Be ta 2-a g o nists

31

I nha le d Co rtic o ste ro ids (lo ng -te rm c o ntro l)

• Be c lo me tha so ne –

(QVAR)

• Bude so nide – (Pulmic o rt)
• F

luniso lide – (Ae ro Bid -M, Ae ro spa c e )

• F

lutic a so ne – (F lo ve nt) L

• c a lly a c ting a nti-

infla mma to rie s

32

Ma st c e ll I nhib ito rs

• Cro mo lyn
• Ne do c ro mil
• I

nte rfe re s with c hlo ride c ha nne ls

• Sta b ilize s ma st c e lls

33

L e uko trie ne Mo difie rs (L T RA)

• Mo nte luka st – (Sing ula r)
• T

a ke a t nig ht

• De c re a se d infla mma tio n
• Bro nc ho dila to r
• Za firluka st – (Ac c o la te )

34

Ora l Syste mic Co rtic o ste ro ids

• Me thylpre dniso ne
• Pre dniso ne
• Pre dniso lo ne
• Gro wth suppre ssio n
• T

a pe r do se s

• Childre n re spo nd to lo we r

do se s

35

Me thyla xa nthine s

• T

he o phylline L iq uid, c a psule s, o r susta ine d - re le a se ta b le ts Mo nito r se rum le ve ls (5-15 mc g / mL a t ste a dy sta te )

36

Antic ho line rg ic s

• I

pra tro pium – (Atro ve nt) De c re a se s c o nc e ntra tio ns o f c GMP to pro duc e b ro nc ho dila tio n No syste mic a ntic ho line rg ic e ffe c ts

37

I mmuno mo dula to rs

• Oma lizuma b – (Xo la ir)

De c re a se s a mo unt o f I g E re c e pto rs o n b a so phils I nhib its b inding o f I g E to re c e pto rs o n ma st c e lls a nd e o sino phils Sub -q inje c tio n e ve ry 2-4 we e ks

38

SABA (I nha le d) “re sc ue ”

• Alb ute ro l
• L

e va lb ute ra l – (Xo pe ne x) Binds to Be ta 2-a ndro ne rg ic re c e pto rs in smo o th a irwa y musc le s Bro nc ho dila to rs Ne b lize rs o r MDI s

39

SCHOOL NURSE

Ro le s a nd I mpa c t o f the Sc ho o l Nurse

40

Asthma re so urc e s fo r sc ho o l nurse s

• E

PR3 fro m the NHL BI – Na tio na l Asthma E duc a tio n a nd Pre ve ntio n Pro g ra m

• NASN we b site
• CDC
• Ame ric a n L

ung Asso c ia tio n

41

Stude nt Co nta c t

• Sc ho o l pe rso nne l (te a c he rs a nd sc ho o l nurse s) spe nd mo re

we e kda y time with stude nts tha n mo st pa re nts

• Be tte r da y-to -da y pic ture o f ho w the y a re func tio ning
• Ab le to c o rre la te misse d sc ho o l da ys with pe rfo rma nc e
• E

va lua te e ffe c tive ne ss o f a sthma tre a tme nt pla n

• I

nput into pla ns

• E

va lua te stude nt’ s unde rsta nding a b o ut a sthma , the ir pla n, a nd c o ntro l

• Pro vide e duc a tio n a b o ut a sthma

42

Sc ho o l Nurse Asthma Che c klist (o r - T he Nursing Ca re Pla n)

• Asse ssme nt (Asse ssme nt)
• Dia g no sis (NANDA)
• Outc o me s (Go a ls)
• Pla nning (I

nte rve ntio ns)

• I

mple me nta tio n (I nte rve ntio ns)

• E

va lua tio n (E va lua tio n)

43

Asse ssme nt (Sub je c tive a nd Ob je c tive Da ta c o lle c tio n)

• K

no w whic h stude nts ha ve a sthma

• Ge t histo ry (trig g e rs, c o nc e rns, c o nta c t numb e rs)
• Ne e ds
• K

no wle dg e

• Ba se line da ta
• T

rig g e rs in the sc ho o l

44

Dia g no sis (NANDA nursing dia g no sis)

• Whic h c a te g o ry o f a sthma do e s the stude nt fa ll into :
• I

nte rmitte nt

• Pe rsiste nt Mild
• Pe rsiste nt Mo de ra te
• Pe rsiste nt Se ve re
• Alle rg ic
• E

xe rc ise I nduc e d

45

Outc o me s (Go a ls)

• Must b e me a sure a b le
• Must b e ma de with stude nt (pa re nts)
• Must b e a tta ina b le
• I

nc lude a time fra me

• E

sta b lish sho rt te rm, inte rme dia te te rm, a nd lo ng te rm g o a ls

• F

a ll into PHCP o utc o me s

46

Pla nning (I nte rve ntio ns)

• Curre nt a sthma a c tio n pla n
• I

ndividua lize d he a lth c a re pla n

• E

me rg e nc y pla n

• I

nput into I E Ps whe n a ppro pria te

47

I mple me nta tio n (I nte rve ntio ns)

• Co mple te a c tio ns
• Co mmunic a te with te a c he rs a nd o the r sta ff c le a r a nd

dire c te d a t the ir le ve l o f unde rsta nding o f a sthma

• E

duc a te te a c he rs a nd sta ff *

48

E va lua tio n (E va lua tio n)

• F

re q ue ntly a sse ss o utc o me s to wa rd g o a ls

• Re -e va lua te the pla n a nd upda te a s

ne e de d

• E

va lua te furthe r e duc a tio n ne e ds o f sta ff

• Ba rrie rs to stude nt c o mplia nc e with the

pla n

• Addre ss a ll a spe c ts (c ultura l,

de ve lo pme nta l, e mo tio na l)

• Re vise a t le a st ye a rly

49

Ro utine o c c urre nc e s

• Ne bulize r

s – a llo ws wa te r o r sa line , me dic a tio n,

a nd a ir to c o me to g e the r a nd the n b e inha le d into the re spira to ry tre e . De sire d b e ne fits a re c le a ra nc e o f pulmo na ry se c re tio ns a nd o pe ning

• f a irwa ys fo r g re a te r g a s e xc ha ng e ,
• Ma y b e use d whe n c hildre n a re una b le to ma ste r

a n MDI a nd spa c e r

• Ma y b e ne e de d fo r a sho rt pe rio d o f time a fte r a n

e xa c e rb a tio n o f URI

50

Ro utine o c c urre nc e s

• Ste ps to using a ne b ulize r:
• Add me dic a tio n (liq uid o nly) to the c up
• Clo se c up a nd c o nne c t tub ing to the a ir

c o mpre sso r

• Whe n c o mpre sso r is turne d o n, it will va po rize

the me dic a tio n, c re a ting a mist

• T

he mist is inha le d b y the stude nt thro ug h the mo uthpie c e – tre a tme nt la sts until a ll the liq uid is g o ne

• E

nc o ura g e the stude nt to ta ke de e p b re a ths during the tre a tme nt

• Impo r

tant to c le a n the c up & mo uthpie c e

a fte r e a c h use – use le mo n-fre e so a p a nd wa te r; dry o n a c le a n to we l

51

52

Ro utine o c c urre nc e s

• I

nha le rs

• Sc ho o l/ distric t po lic y a b o ut stude nt c a rrying o f inha le rs
• F

re q ue nc y o f use o f re sc ue inha le rs (SABA i.e . Alb ute ro l)

• Ro utine use b e fo re re c e ss o r e xe rc ise
• Dx: e xe rc ise induc e d a sthma
• Co rre c t use o f inha le rs
• Ae ro c ha mb e r o r spa c e r
• Slo w inha la tio n, c o unt, e xha le , wa it, re pe a t

53

Co ntro ve rsy a b o ut pre -tre a tme nt with SABA b e fo re re c e ss No e vide nc e to suppo rt, no re c o mme nda tio n fro m E PR3 Prio r to re c e ss, no re sc ue is ne e de d

Ro utine o c c urre nc e s

• Ho w to use a me te re d do se inha le r (MDI

) with a spa c e r o r a e ro c ha mb e r (a lo ng tub e tha t slo ws the de live ry o f me dic a tio n fro m a pre ssurize d MDI )

• Sha ke the inha le r we ll b e fo re use (3-4 sha ke s)
• Re mo ve c a ps fro m MDI

a nd spa c e r

• Atta c h the MDI

to the spa c e r

• E

xha le

• Bring the spa c e r to the mo uth, put the mo uthpie c e b e twe e n

te e th a nd c lo se lips a ro und it

• Pre ss the to p o f the inha le r o nc e
• Bre a the ve ry slo wly until a full b re a th ha s b e e n ta ke n. **he a ring a

whistling so und indic a te s b re a thing wa s to o fa st**

• Ho ld b re a the fo r a b o ut 10 se c o nds, the n e xha le .
• Wa it 3-5 minute s a nd re pe a t if 2 puffs ha ve b e e n pre sc rib e d

54

E me rg e nc y inje c tio ns

• E

pine phrine pe ns

• E

pine phrine (E pi) inje c tio n is use d to tre a t life -thre a te ning a lle rg ic re a c tio ns c a use d b y inse c t b ite s, fo o ds, me dic a tio ns, la te x, a nd o the r c a use s.

• Sympto ms inc lude : whe e zing , sho rtne ss o f b re a th, ta c hypne a , hive s,

itc hing , swe lling , sto ma c h c ra mps, dia rrhe a , a nd lo ss o f b la dde r c o ntro l.

• E

pine phrine is a sympa tho mime tic a g e nt; wo rks b y re la xing the musc le s in the a irwa ys a nd tig hte ning the b lo o d ve sse ls.

*sc ho o l/ distric t po lic y re g a rding stude nt c a rry a nd sto c k e pine phrine

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E me rg e nc y inje c tio ns

• Ste ps to g iving a pe n e pine phrine inje c tio n

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PRACT I CE

Ha nds o n pra c tic e a s de sire d

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QUE ST I ONS

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