A Partnership in Treating Childhood AsthmaAsthma affects approximately 10.1% of children living in the United States, and continues to be the most common chronic childhood illness (“Strategies,” 2002). Some risk factors that account for this startling percentage of children with asthma include age, heredity, gender, children of young mothers under age twenty, smoking, ethnicity (African American are at greatest risk), previous life threatening attacks, lack of access to medical care, psychological/psychosocial problems, underdiagnosis, and undertreatment (Hockenberry, 2003). The nurse plays a vital part in identifying modifiable and non-modifiable risk factors, and educates both parent and child on effective ways to control unwanted asthmatic attacks through self-care education and participation in asthma management programs.
The responsibility of caring for a child with asthma should be shared equally between the adult caregiver (i.e., parent, relative, or teacher) and child. The overall objective is to avoid or reduce exposure to triggers that tend to precipitate or aggravate asthmatic exacerbations; however, these precautions should not sacrifice the child’s normalcy in development and socialization. At present, nurses are given the opportunity to fully enact their roles in terms of case management; client advocacy in both school and health care systems; education of children, parents, teachers, and support for children and families as they learn to master the complexities of managing a chronic illness (Horner, 1999). For the child, there are six themes that need special attention upon initial diagnosis: worries, asthma knowledge, school issues, medications, parental support, and the desire to be normal (Ming & McConnell, 2002). The ability of the nurse to address initial and ongoing parental concerns, as well as those of the child, will foster an effective nurse, parent, and child partnership in managing childhood asthma.
AssessmentA school age girl (7 years-old) is brought in to the emergency department (ED) with the following symptoms: Wheezing and dry cough; prolonged expiration, restlessness, fatigue, and tachypnea. Her chest x-ray reveals hyperinflation of the airways, and a pulmonary function test reveals reduced peak expiratory flow rates (PEFR). Upon completing a physical assessment the nurse notes skin as cyanotic, and a use of accessory muscles for respiration but no signs of an abnormal chest configuration. Nurses assist with diagnostic tests, pulmonary function tests, and skin testing, as well as a general health assessment. Nurses also obtain assessments of how asthma impacts the child’s everyday activities and self-concept (Hogan & White, 2003). The pre-diagnosis phase of a child’s asthma is a time of fear, and it is both desirable and necessary for the nurse to create a good nurse/parent partnership. A good partnership involves, among other things, understanding a family’s situation, knowledge about the disease and its treatment, and open communication between parent and nurse (Englund et al., 2001).
The nurse continues with the assessment by asking the parents if there is a family history of asthma or respiratory dysfunction. The nurse also asks if either of them smokes and if they have any family pets. Upon completing a family and social history the nurse learns that both parents smoke, they live with two dogs, and that the maternal grandfather had asthma. The child is not currently on any medication and has no known allergies. The nurse continues with the assessment by asking the parent and child questions pertaining to frequency of day/night symptoms, frequency of exacerbations, and limitations regarding physical activity (Hockenberry, 2003). After interviewing the child and parent, the nurse learns that the child has had daytime symptoms during soccer practice and games, and nighttime symptoms once over the last month. Collecting subjective/objective data from the parents and child and utilizing examination results found in the child’s chart will enable the nurse to accurately prioritize one or more nursing diagnoses relevant to caring for childhood asthma.
AnalysisThe nurse will use a combined approach involving parent, child, and school in developing a multi-dimensional list (physical dimension, personal dimension, and social dimension) of the child’s current/potential strengths and stressors. Evaluation of these domains will aid the nurse in forming and prioritizing appropriate nursing diagnoses.
The child’s current strengths include: Physical – developmentally in line with fine/gross motor skills; Personal – enhanced self-esteem when participating in school activities; and Social – positive peer relationships with peers at school and soccer team.
The child’s current stressors include: Physical – unable to play soccer for more than thirty minutes without feeling asthmatic symptoms; Personal – Feelings of powerlessness, anxiety, and fear associated with asthmatic episodes; and Social – being teased by her team members after being called out of the soccer game due to asthmatic symptoms.
The child’s potential strengths include: Physical – able to participate in favorite physical activities by properly using long-term control, preventative, and quick relief medications; Personal – develops a sense of achievement and competence in self-care of asthma; and Social – teachers, coaches, and parents form a partnership in helping the child maintain a sense of normalcy while actively supporting her asthma management.
The child’s potential stressors include: Physical – Unable to play soccer and other favorite physical activities; Personal – fear that school faculty, peers, and family are treating her differently because of her asthma; and Social – lose of friends and isolated by team members.
By utilizing the assessment data gathered in order to generate a list of strengths and stressors for the child, the nurse is able to begin formulating the child’s multi-dimensional nursing diagnoses.
Nursing DiagnosisA nursing diagnosis is an individualized statement considering the client’s personal, physical, and social dimensions. It is a conclusion drawn from the data collected which serves as a means of describing a health problem open to treatment by nurses. It is with this in mind that nurse has formulated the following nursing diagnoses.
The child’s nursing diagnoses in physical dimension include: 1) Risk for suffocation related to respiratory dysfunction as evidenced by wheezing, coughing, and/or prolonged expiration; and 2) Activity intolerance related to an inability to play a full game soccer as evidenced by rapid labored breathing and fatigue.
The child’s nursing diagnosis in personal dimension includes: 1) Risk for ineffective management of therapeutic regime related to insufficient knowledge of asthma, self-monitoring of symptoms, maintaining a symptoms diary, medications, use of peak-flow meter, avoidance of exposure to asthmatic triggers and allergens, and community asthma programs; and 2) Risk for situational low self-esteem related to an inability to fully participate in developmentally appropriate physical activities.
The child’s nursing diagnosis in social dimension includes: 1) Altered family processes related to centering family decisions and activities on the needs of the asthmatic child.
Once the child’s problems have been prioritized, the goals for treatment are established. Goals are broad directions to guide the plan of care. A long term/discharge goal indicates the overall end-result of care, although it may not be achieved prior to discharge. Expected client outcomes are the desired results of actions taken and achieve the broader goal and are the measurable steps to achieve the goals of treatment/discharge criteria.
Patient OutcomesProviders, parents, and children can collaborate to set goals for symptom reduction and increased school attendance and participation in sports. Nursing guidelines for writing expected client outcomes are based on the premise that outcomes should be easily understandable, and if clearly written, should enhance communication and continuity of care. The National Heart, Lung, and Blood Institute (NHLBI) guidelines for patients state that parents should ‘expect nothing less’ that the following: the child has no symptoms or only minor symptoms of asthma; the child sleeps through the night without asthma symptoms; no school days are lost because of the child’s asthma; the child requires no ED visits or hospitalizations because of asthma; the child can participate fully in peer activities; and the child exhibits few or no side effects from asthma medications (Gallagher, 2002).
In addition to NHLBI guidelines, the nurse will ensure that the child is able to successfully self-administer asthma medication prior to discharge, as well as verbalize the reasoning for time and frequency of administration. The child should also be able to correctly use a peak flow meter and incentive spirometer prior to discharge and demonstrate how to properly record results in an Asthma Symptoms School Age Diary. Within the diary, the child will also demonstrate how to accurately record difficulty in breathing or complaints of shortness of breath, fast breathing, impaired speech, wheezing, coughing, complaints of chest pain or a sensation of heaviness or tightness, sleep interruptions (resulting from wheezing or coughing), involuntary drawing in of muscles between ribs, and diminished level of awareness (Gallagher, 2002).
Developing realistic and age appropriate short-term and long-term outcomes are an integral part of the nursing process, and central to the planning and implementation stage of nursing care. In this stage of the nursing process it is helpful for the nurse to keep a record of client teaching, because education covering basic asthma information can take at least three to six 20-minute visits (“Strategies”, 2002).
Planning and ImplementationOne opportunity for nurses to educate patients and families occurs during acute care visits, and particularly during emergency department visits. These visits can be uses to motivate the child and the family to learn more about asthma and appropriate self-management Some topics to cover include: Eating a well balanced diet, taking sufficient rest periods, and gradually increasing activity in order to promote overall good health and increases the resistance to infection; use of an incentive spirometer in order to encourage deep, sustained inspiratory efforts; teach a leaning forward position in order to enhance diaphragmatic excursions and diminishes the use of accessory muscles; teach pursed-lip breathing in order to prolong exhalation, preventing air trapping and air gulping; teach and observe the proper use of a hand-held nebulizer, oxygen therapy, and/or inhaler in order to prevent medication overdose or prevent oxygen dependence.
Teach the parents and child that improper use of inhalers has been outlined as an antecedent of asthma. Clients tend to overuse inhalers, leading to their ineffectiveness; and develop an exercise routine in order to increase the child’s stamina. Warn the child that improper exercise may trigger asthma. Instruct the child to avoid exercise in extreme hot or cold weather. Wearing a paper mask may reduce the sensitivity to stimulants. Emphasize the importance of cool-down period. Suggest swimming and exercises indoors to avoid exposure to stimulants (Lippincott, 1999).
During these visits patients and their parents should be instructed in immediate interventions and danger signs. Instruct the client to report the following: change in sputum characteristics or failure of sputum to return to usual color after three days of antibiotic therapy in order to identify an infection or resistance of the infected organism to the prescribed antibiotic; elevated temperature because circulating pathogens stimulate the hypothalamus to elevate body temperature; increase in cough, weakness, or shortness of breath because hypoxia is chronic, and exacerbations must be detected early to prevent complications; and weight gain or swelling in the ankles or feet because these signs may indicate fluid retention secondary to pulmonary arterial hypertension and decreased cardiac output (Lippincott, 1999).
The nurse must also take the time to explain the hazards of an upper respiratory infection (URI), and suggest that the child avoid contact with infected persons, and receive immunization against influenza and bacterial pneumonia. Instruct the parents that children who receive immunotherapy for seasonal allergies may have a lower risk of developing asthma according to a recent study in Nursing. By preventing the immunologic response to allergens, immunotherapy may interrupt the natural progression of allergic disease, which may lead to asthma (2002). The nurse should also strongly recommend that the child take antibiotics as prescribed if sputum becomes yellow or green, and adhere to medication and hydration schedule. In addition, it is thought that URI causes inflammation of the bronchial tree, leading to bronchoconstriction and air trapping (Lippincott, 1999). Adhering to the nursing guidelines and avoiding potential triggers could minimize the chances of the child acquiring an URI.
The following is a list of common triggers, or modifiable risk factors, that tend to precipitate or aggravate asthmatic exacerbations: Outdoor allergens: trees, shrubs, weeds, grasses, molds, pollens, air pollution, and spores; Indoor allergens: dust or dust mites, mold, and cockroach antigen; Irritants: tobacco smoke, wood smoke, odors, and sprays; exposure to occupational chemicals; exercise; cold air; changes in weather or temperature; Environmental change: moving to new home, starting new school, etc.; colds and infections; Animals: cats, dogs, rodents, and horses; Medications: aspirin, Nonsteroidal anti-inflammatory drugs (NSAIDS), antibiotics, and beta-blockers; Strong emotions: fear, anger, laughing, and crying; Conditions: gastroesophageal reflux, and tracheoesophageal fistula; Food additives: sulfite preservatives; Foods: nuts, and milk/dairy products; and Endocrine factors: menses, pregnancy, and thyroid disease.
Parental smoking and the child’s two family dogs are modifiable risk factors that appear on the list of common triggers. Not smoking near their child or to quite smoking is within the parent’s ability to make changes in the home environment. This course of action is likely to provide better asthma management and prevent more serious asthmatic episodes (McCarthy et al., 2002). However, careful consideration must be taken when removing family pets from the home, because the psychological anguish of the child may outweigh the benefit of decreasing the frequency of asthmatic episodes.
It is important that nurses discover the beliefs, misconceptions, and expectations of the families they serve. This can be done by using simple, open-ended questions and by approaching the family in a non-judgmental manner. Each belief and misconception should be acknowledged, and then gently refuted by factual information. General questions such as, “What do you know about asthma?” “What are some of your concerns about having asthma?” “What problems are you having taking your medicine?” can serve as the beginning of these teaching sessions. In this way, the patient or parent can be helped to understand the disease and its appropriate treatment. It is also important for the nurse to keep a detailed record of these teaching sessions so he or she can refer to what was said and what was taught when future visits occur (“Strategies”, 2002).
During the first visit the nurse should ask what the patient/family expects the asthma treatment to achieve, for this question can uncover many misconceptions. Parents often believe that children with asthma should not go outside or participate in sports; many also believe that their child will eventually “outgrow” asthma. In addition, the child and family should be taught the nature and cause of the asthma, the two primary treatment methods (preventers and relievers) and how they work, when to seek medical help, and proper inhaler use. Also during the visit a self-management plan should be codeveloped and agreed upon. It is essential to be concrete and specific with all instructions, telling the patient exactly when and how to take her medication (“Strategies”, 2002).
In 1995 the NHLBI developed a classification of asthma based on the following four categories: mild intermittent, mild persistent, moderate persistent and severe persistent. Understanding the level of treatment associated with each classification of asthma will enable the nurse to implement the appropriate plan of care. The seven-year-old child has been diagnosed with the lowest classification of asthma, mild intermittent asthma, and should be told that daily medications are not required at this time; however, in the event of an asthmatic episode, emergency or quick relief treatment can be attained through the use of a short-acting bronchodilator (Gallagher, 2002). However, the parents should know that the existence of only one symptom of greater severity is enough to warrant classifying asthma as more severe. Nevertheless, there are multiple opportunities for error in symptom perception and management. A study in Nursing Research concluded that families lack accuracy in symptom identification and asthma symptomology. The child and/or family may not be accurate in assessing the physical parameters of the symptom, they may attend to the wrong symptom, or they may wait too long to intervene. In fact, a majority of the families being studied correctly identified wheezing as an asthma symptom, but seemed to ignore coughing (1999).
A case control study of children with asthma, ages zero to 14, revealed that a written asthma management plan was associated with reduced risk of hospitalization and ED visits (Gallagher, 2002). Management plans, which are based on asthma severity assessment, provide information regarding both routine and emergency asthma care, including how to evaluate an emergency situation and respond appropriately to it.
Provide the parents with a CPR/First Aid course schedule and encourage them to take the class together so that they may learn how to administer proper care in the event that their child stops breathing. Instruct the parents and child that the use of a peak flow meter will enable them to identify the need for medical intervention when physical early warning signs are missed. The nurse will instruct the child and parents to keep a diary of peak flows for 7 days (every morning and at bedtime). If the beta-antagonist is needed, measure peak flow before and after using and document. Determine the child’s personal best peak flow by marking the line. Based on the child’s personal best peak flow (100%), the nurse will show the parents how to calculate zones: Green – 80-100% of personal best, Yellow – 50-80% of personal best, and Red – Below 50%. If the peak flow is in green, no intervention is needed. If the peak flow is in yellow, a Beta2-Antagonsit inhaler is used and the parent will call the primary provider if there is a negative response. If the peak flow is red, the parents will take their child to the emergency room if there is a negative response to initial therapy or if peak flow is <>
EvaluationsPeriodic assessment of the family and child should be conducted to enable the nurse to observe changes over time (McNelis et al., 2000). The NHLBI guidelines recommend a regular follow-up visit at one to six month intervals, with modification of the management plan as needed (Gallagher, 2002).
The reason families fail to adhere to medical treatments are as numerous and varied as the families themselves. In most cases there are complex sociological and psychological factors, which influence the family’s behavior. Therefore, in order to best serve patients with asthma, it is appropriate for the nurses to learn more about the families. Routine assessments of family health and cultural beliefs, knowledge of asthma, beliefs regarding self-care, and the family’s financial ability to purchase medications can be important strategies in enhancing adherence (“Strategies”, 2002).
Children’s perceptions are important because they are linked to behaviors, including health behavior and management of the asthma condition. Interventions may be needed that enhance children’s positive coping behaviors, enhance positive attitudes, and increase satisfaction with family relationships. Interventions that address concerns and fears about having asthma might also help them develop more positive attitudes. Nurses might need to preferentially target girls who have severe asthma for participation in programs to specifically enhance self-concept, such as support groups and counseling. Additional strategies for enhancing positive attitudes might include providing role models, such as famous athletes or people who excelled in their pursuits despite an asthma condition (McNelis et al., 2000).
In a study conducted by Rydstrom, Englund, and Sandman, children described feelings such as guilt when they said that they felt responsible with other people had to give up certain things (i.e., pets, hobbies), and that their disease meant extra work for people in their surroundings. Medications were also very important to the children in this study. Medications can offer help to give children with asthma normal lives. The study results seem to indicate that children with asthma, to a greater extent than healthy children, reflect more on what living a normal life really means, as they do not have the possibility to live normal lives. It is perhaps true that what seems quite natural to healthy children becomes a goal for children with asthma to attain (1999)
The child ignored early symptoms, and this may be viewed as a desire to be “normal” since ignoring early warning signs results in worsening of symptoms and ultimately, greater interference with activities of daily living (Meng & McConnell, 2002). It seems as though she perceives her parents’ constant treatment reminders as negative or controlling feedback. It is possible that the child and parents perceive feedback from healthcare professionals as evaluative or controlling, as well. If this is the case, lack of internal motivation may lead to continued non-adherence decisions if not properly managed by the nurse.
In addition, the parents failed to recognize that nocturnal symptoms as an indicator that asthma is uncontrolled; hence they failed to make decisions that resulted in the child asthma classification raising from mild-intermittent to mild-persistent and a need for controller medication. Her parents also reported difficulty distinguishing a pseudo attack (common cough) from a true attack (asthma cough). Despite this inability, her parents were not using a peak flow meter consistently as an objective measure (Meng McConnell, 2002).
Both parents and child underutilized trigger avoidance strategies. The child’s behavior may be a reflection of the parent’s behavior since parents reported little active trigger avoidance decisions. Since her parents failed to make trigger avoidance decisions, it is unlikely that they proactively supported the children in this behavior (Meng McConnell, 2002).
The child was clearly concerned about having an attack at school, and not having access to medication or having to prove a need for it. The child’s greatest concern was exercise-induced asthma while at physical education class. The distance from the gym to the opposite side of the building where the medications were stored in the clinic caused anxiety that they would not have her medication in time of need. She recognized that slow warm-ups could prevent exercise-induced attacks but she pointed out that she did not always have control of this decision since many coaches direct otherwise (Meng McConnell, 2002).
The inhaler possession issue is crucial to this age group. Parents recognized the need to adhere to school policies, yet at the same time found the need to have the inhaler with the child. The children had learned to depend on the inhaler being with them or their mothers at all times, and this school policy represented a break in that security. Forcing children to “prove” their need for an inhaler to an adult before they can access it is challenging. According to Erikson, loss of control is a major stressor for school aged children, and the loss of the inhaler is, thus, a major event for some children (Palmer, 2001).
A study conducted by Horner revealed that there are important implications for nurses who work with children who have asthma. Clearly, nurses should create opportunities to educate teachers, coaches, school office staff, and others about the signs, symptoms, and seriousness of childhood asthma (1999). School nurses could partner with families to develop individualized asthma management plans for each child. These plans should include medication needs, activity restrictions or limitations, and method of contacting the parents (Palmer, 2001). At this time the parent or nurse must take it upon themselves to make special arrangements for a school nurse and school faculty to participate in a child’s asthma management program. Research studies supporting a need for a change in school guidelines will aid in convincing the Department of Education to implement a national policy on asthma education and screening in public schools.
Further ResearchNurses in the public school system currently screen all children for vision problems and hearing disorders, but why can’t children be screened in school for asthma and other allergic diseases (Rollins, 2002)?” Further research on this topic could explore the cost-to-benefit ratio of student screening and specialized training requirements in order to implement these much needed screening procedures. Another research topic of interest is identifying whether or not school buildings are a significant source of asthmatic allergens.
In one such study, according to a March 4, 2002, news release from the American Academy of Allergy, Asthma, and Immunology, removing rugs and carpets from schools could help reduce symptoms of asthma, as well as prevent the development of asthma in children. Researchers in Baltimore performed visual assessments of Baltimore’s public schools in an effort to determine why 10% to 20% of the children in that city have asthma when the national average is 7.5%. In addition, researchers analyzed dust samples for dust mite, cat and dog, cockroach, and mouse allergens. Although each of the allergens were present to some degree in all study locations, schools with rugs or carpets were found to have a higher level of cat and dog, cockroach, and mouse allergens, creating a potentially higher trigger for asthmatic reactions (“Allergens”, 2002). Not all allergens are necessarily bad; in fact, the next study takes a look specifically at a potential benefit of being exposed to dog allergens at an early age.
Even though the family pet may be a significant source of allergens to the asthmatic child, they are more than just an animal; they are a part of the family. One research study gives light to a hope that the family pet may actually decrease the child’s likelihood of acquiring asthma. A prospective study conducted by Ownby, Johnson, and Peterson, designed to examine multiple risk factors for allergic sensitization at 6 to 7 years of age, revealed that exposure to two or more dogs or cats in the first year of life was associated with a significantly lower probability of subsequent allergic sensitization to common aeroallergens. Exposure to two or more dogs or cats was also associated with significantly lower IgE concentration, less methacholine airway responsiveness, and better lung function in boys but not in girls (2002). Further research needs to take place in order to understand why only boys were affected and not girls. Furthermore, it would be interesting to know if these results applied to other animals as well.
Summary and conclusionMoving from the traditional to an empowering approach represents a paradigm shift for health car providers and clients. An empowering approach requires a new way of working with clients that is based on a participatory help-giving philosophy and changes the role of the health care professional from that of an expert provider to a partner in care. Many professional have a tendency to do things for families without considering the consequences of this “fix it” philosophy. While taking control and solving problems for families may be expedient in terms of time, it deprives families of the opportunity of learning to develop the competence and skills to solve their own problems (McCarthy et al., 2002). Empowering the child, parent, and school to take equally active roles in the child’s asthma management will ensure prevention and medication adherence without sacrificing the child’s independence and self-esteem.
