This paper includes a nursing care plan for asthma education. The final paper for the nursing pharmacotherpeutics class in the RN to BSN program was to write a paper and educational plan based on a need related to pharmacology and nursing. This student chose to discuss the issue of a need for more asthma education for parents based on the frequency of emergency room visits at a pediatric facility. It is important for parents to understand the rationale for keeping asthma medication on hand and to administer it when needed.
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Pharmacology paper including a nursing care plan for asthma education
Childhood Asthma Education
Despite the availability of effective medications, asthma continues to be one of the most common childhood chronic illnesses. (McMullen, Yoos, Anson, Kitzmann, Haltermann & Sidora-Arcoleo, 2007.) The 2006 Texas statistics report that 599,000 children have asthma. (Texas Department of State Health Services, 2008) Many resources are available in relation to asthma yet many children present to the emergency room each year due to poor management at home. As a nurse in a large pediatric hospital I see many children admitted to the hospital for asthma treatment. Many of these children do require admission, while appropriate home management in others would have avoided the admission and maybe the emergency room visit as well. A common occurrence at this hospital is a family presenting to the emergency room with a wheezing child because they ran out of medication or did not take it with them. Why does this happen? I do believe things such as medications can be forgotten, but I see this scenario more than I would like, and this is only one hospital. Information regarding asthma is available yet these families we encounter are not aware of it. Based on this information a more comprehensive program is needed. A program that is much more readily available to the general public with a much louder voice to be heard. Everyone who needs information about asthma and its treatment should have access to an educational program. Over the past few years I have personally witnessed this type of situation numerous times at this large pediatric hospital in Harris County, Texas. The fact that this occurs so frequently brings up the question of why. Many thoughts come to mind from noncompliance to lack of education or lack of funding. Unfortunately with many of the cases where the medications had run out the story told to healthcare professionals changed each time it was given. Being a personal witness to this issue, and also having a child of my own with asthma, I am interested in the available resources to families with asthmatic children. National programs are available for educational purposes, physicians educate in their offices, and hospital programs exist for children who do get admitted for asthma. Yet there are still children who are not receiving the proper home management for their asthma. As a nurse in Harris County I see a need for more asthma education in general, but specifically to children with asthma and their families. I would like to see some of the programs that are already available come together with a louder voice so that the residents of Harris County know that these programs are out there. I would love to see more education in relation to the different types of asthma medications available and what they are for. A focused campaign reminding everyone to always have emergency medications on hand and to remember to refill prescriptions would be very beneficial. An outline of a proposed asthma education for Harris County is outlined in Appendix A.
The National Asthma Education and Prevention Program’s guidelines emphasize that effective asthma education should involve a relationship between the health care provider and the parent. (as cited in McMullen et al., 2007) Per McMullen et al (2007) despite these guidelines many parents report that they did not receive enough information related to the diagnosis of asthma or the different medications prescribed. This report also covers the most and least discussed topics, as reported by the parents. Parents reported that they were most frequently taught how to use a metered dose inhaler, how to manage an attack and were advised on the effects of smoking and smoke exposure. According to the parent’s reports, the topics discussed the least were the goals of asthma management, the child’s feelings toward asthma, and a written plan as to when to call the primary care provider (PCP) or go to the emergency room. Parents of children with more severe symptoms did report more education received, but this is likely due to more contact with the PCP. Also parents with higher education and socioeconomic status reported less education, this report may be parent perception, but it is a fact to take note of. (McMullen et al.) An education plan should involve all families of asthmatics no matter how severe the symptoms, without regard to educational or socioeconomic status, and the education should include all of these topics. It should also include an open relationship between the family and the PCP or specialist office. This is especially important because these studies have shown that ineffective communication in this area can lead to non-adherence in the prescribed therapy. (McMullen et al.)
Asthma Education Classes
Research studies have been performed to evaluate asthma education to families. These studies have shown that the classes are most effective when taught by the same staff that works at the asthma clinic or pediatrician’s office. The research showed that parents felt more comfortable with the health care personnel that they already knew. They were more comfortable asking questions and more comfortable calling the clinic with questions later on. The education classes offered in this format tended to open up communication between the health care providers and the families. A comment that came out of this study from one family was that they needed to know their concerns were taken seriously. The feeling after education from their own provider was that their concerns were valued. (Trollvik & Severinsson, 2005) This type of education also helps the families to feel empowered. Studies have shown that parents and children are more compliant when they feel empowered. The studies showed that they felt empowered by using the peak flow meter and following the asthma action plan. The feeling of empowerment came from feeling that they were in control of the asthma symptoms. These families were more likely to be adherent because they felt more in control. (Burkhart, Rayens, Oakley, Abshire, & Zhang, 2007)
This research study by Trollvik and Severinsson (2005) also found that parent education was better understood when the child was not present. They found that the child often became impatient which made it hard for the parents to stay focused on the education and concentrate on the information. Based on this research an asthma education program would be provided where the parents can relax without their children and take in the information being offered. A parent focused video would be included as well as verbal and written instruction. This instruction would include information of what asthma is, the symptoms and triggers as outlined in Appendix B and information on medications as outlined in Appendix C. The asthma action plan would also be reviewed with an assignment to complete the peak flow meter testing and review with the PCP to create an individualized plan. Research has shown that adherence to monitoring of peak flow meter readings has been associated with decreased asthma episodes. (Burkhart, Rayens, Oakley, Abshire, & Zhang, 2007) This research would be used to emphasize the importance of peak flow meter use. In another room the children would be receiving education in a shorter format geared towards their knowledge level and attention span. Designated classes would be provided for different age groups to allow for age appropriate activities. This would provide parents the opportunity to attend class, as well as offering education to the children. A child focused video and puppet show would be offered that covers signs and symptoms and medications. A main focus would be when and how to give medication as well as always having the rescue inhaler handy and refilling prescriptions before they run out. The children’s class would be shorter to allow for their shorter attention span and allow question time and then playtime at the end. This playtime would include “playing” with an inhaler and spacer, a nebulizer machine and a peak flow meter.
An asthma program must include information on the different types of asthma medications available. Information offered for this program would include the statement that medication should be prescribed by the child’s PCP or asthma specialist, and these medications should not be shared with others. This information would also include the need to take maintenance medications even when symptoms are not present. Appendix C discusses information on asthma medications that would be included in this program. Specific drugs would be discussed on an individual basis as needed. Everyone would be given general information on rescue and maintenance medications. The National Asthma and Education Prevention Program includes asthma treatment goals. The guidelines include adjusting medication type, dosing and frequency based on the level of asthma symptoms present. (as cited in Yoos, Kitzman, Halterman, Henderson, Sidora-Arcoleo, & McMullen, 2006) Despite these guidelines studies have shown that many children who should receive preventative treatment do not. A variety of barriers lead to this problem, including the PCP, health care system and family/patient barriers. Yoos et al (2006) provide statistical research that shows “only one half to two thirds” of children with persistent symptoms were prescribed maintenance medication by their PCP, and “nearly one third of these prescriptions are never filled.” (Yoos et al., p. 385) Beyond the filling of the prescription there is also a poor level of adherence noted with studies suggesting only 50-60% of doses prescribed are taken. (Yoos et al.) The family barriers found in this study included non-adherence to treatment, inaccurate assessment of symptoms, failure to seek medical care when needed, and misperception of asthma being under control. (Yoos et al.) All of these factors could be minimized with an educational program offering complete asthma information and leading to open communication between the families and the PCP.
A family receiving a prescription for asthma medication should receive information about the medication, as well as how it should be taken. This education should include the use of inhalers, spacers or nebulizers if applicable. An inhaler must be used correctly for the child to receive full effects. It is important that this education takes place and that the patient or family demonstrate its use afterwards. It is also important to have them demonstrate use periodically to ensure is it being used properly. (Leyshon, 2007) Pressurized metered dose inhalers (pMDI) require both coordination and good inspiration which can make it difficult for some, especially young children. In this circumstance a spacer device is a wonderful tool. The spacers “are holding chambers which trap the medication after it is released from a pMDI, allowing more time for medication to be inhaled.” (Leyshon, p. 38) It is the recommended choice for delivery of these medications to children under 5 years of age. It is also highly recommended for children 5-15 years but alternate devices can also be considered for this age group. Lifestyle factors should be considered as the size of the spacer is much larger than the inhaler itself. Ultimately, the most effective inhaler device is the one that leads to best adherence to the medication regimen prescribed. (Leyshon)
Disease Management/ Case Management
Yoos et al. (2006) refer to children with persistent symptoms who do not seek care as “silent sufferers.” They report that the high numbers of silent sufferers found in their study shows that parents will not always initiate contact with a health care provider. A proactive approach from the health care team for follow up and regarding education may play an important role. Case management or disease management programs are growing in popularity. Many insurance companies provide programs and education for their members. They offer telephone education and follow up calls on any problems and to see if the education plan was followed. Some also send out packets of useful tools that included an asthma diary, a peek flow meter, a spacer, an action plan, and written informational materials. These programs are available and not everyone is aware of it, and not everyone who could benefit is referred. This type of program would be a great resource to be available to all children, not only those with a particular insurance. A county program offering this service to all Harris County residents would be a wonderful addition to an education program. To get this portion of a program up and running notification of the program would need to be publicly advertised with TV spot ads and newspaper articles. Marketing and education to pediatrician offices, asthma specialists, family practitioners, clinics, and hospitals to promote the program would also need to be done to ensure children would be referred to the program appropriately. As well as physician referrals, patients and families could self refer and the PCP would be notified that their patient had entered this program.
As well as a disease management program which is more of a proactive program, there also is a need for a reactive program. This reactive program would be in the form of an asthma helpline. This line would be where individuals would call for themselves or for another individual and ask questions. This line would cover education in general as well as what to do when a family calls trying to deal with an asthma attack. This type of program could offer both audio feeds for them to listen to, including some that would play during any hold time, as well as live medical personnel to talk to. All of the staff would be trained in asthma education. A study of the Asthma Action Helpline that is associated with the Ontario Lung Association showed that the calls tended to occur when asthma was not under good control. Many times these callers wanted an opinion on whether they should see their PCP. They also noted confusion by the callers regarding the roles of the different asthma medications. These calls into the helpline represent teachable moments and the staff were able to take advantage of that time. (Cicutto & Ashby, 2007) At the time of the call the disease management program can be explained and enrollment offered. If the family agrees the child can be enrolled and the PCP would be notified. This program would also include information about support groups in the area. A search for support groups at the Asthma and Allergy Foundation of America (www.aafa.org) provided only 1 in all of Texas and it was located in Midland, TX. More support systems are needed for families of children with asthma. Support groups may not be needed by all, but for those who choose to attend they may be helpful. Parents’ sharing information and ideas is a great concept. A support group also allows for the families to have someone to share with that would understand what they are going through. These support groups would be led by medical personnel trained in asthma education to ensure appropriate medical information is shared. Reinforcement of education would be a small part of every meeting.
Overall asthma education does exist in Harris County, but the studies show that parents do not feel that they receive enough training. The fact that children present to the emergency room without medications shows that more emphasize on this education is needed. In cases of true noncompliance we may not always make a difference but this program being presented to the community from a variety of angles may allow the information to be spread out to more people. Advertising the disease management and education programs will hopefully lead to more families being followed by health care professionals. Training offered by the families own PCP may open up the lines of communication. Advertisements geared toward always having medications on hand would hopefully have that important piece of information spread out to the community. These ads gears toward both children and adults, would hopefully promote the family working together as a team. Together the parent and child, with help from these available resources, can learn how to appropriately manage their asthma. They will learn the importance of preventative treatment that can help to keep them healthy and help avoid both hospital admissions and emergency room visits.
Outline for Childhood Asthma Education
1. Develop a video (one for parents and one for children) and brochure that includes: - What asthma is - Information about the different types of asthma medications, including their use, side effects, when and how to administer. - signs and symptoms of asthma - determining and avoiding triggers - discussion on using an asthma action plan - how to access the helpline and disease management program - support groups available
2. The video and brochure would be used to offer information to both the public and delivered to pediatrician and asthma specialist offices to be given to patients or used with their education program.
3. When visiting the pediatrician offices these offerings would be given as well as a guideline for offering asthma education classes to their patients. An educational program should be fairly standard and should follow the evidenced based guidelines. All programs should include the use of the asthma action plan as well as all other information covered in the video and brochure. Classes should be held for both children and parents, preferably separately and to come together as a group at the end.
4. Initiate an asthma helpline available to all of Harris County. Advertise this concept through TV and radio spots as well as in the Houston Chronicle and local parenting resource guides.
5. Initiate a disease management program available to all residents regardless of insurance. Referrals may come from PCP’s or families may self refer. Advertisements through TV and radio spots as well as in the Houston Chronicle and local parenting resource guides. This program would send participants a packet that includes more written information in an easy to follow guidebook (binder style to allow additions), an asthma diary, an asthma action plan to take to their PCP, a peak flow meter, a spacer, information about support groups and coupons for asthma medications (that would require a prescription).
6. Coordinate support groups in several areas throughout Houston to make it convenient for people to attend. Again, advertise through TV and radio spots as well as in the Houston Chronicle and local parenting resource guides.
7. A TV and radio spot to be developed that includes information about always having asthma medication on hand. “Don’t leave home without it!” and “Never run out of your asthma medication!” These TV spots should draw the attention of both children and adults and a possible spokes person could be Hannah Montana and/or the Jonas Brothers offering a catchy song that will stay in their heads to remind them not to go without their medication. As spokespeople these would appeal to the children.
8. Mini Health fairs would be offered at places such as Wal-mart, Kroger, Randall’s, and other locations that sell prescriptions as well as at the local malls. These would offer education on peak flow meter, inhaler use, enrollment in the disease management program, offer the brochure and helpline information. Posters and education would also include information on having medications available at all times.
9. Information regarding this program would also be presented to area school districts, specifically to school nurses. Along with this program would be encouragement that all children with asthma have an asthma action plan filed at their school. This would allow the school nurse to know the child’s baseline status and plan as well as be a way to make sure that all children have an asthma action plan.
Asthma Symptoms and Triggers
Many individuals with asthma have specific triggers and they would be
encouraged to pay close attention to this to learn what their own
(National Heart Lung and Blood Institute, n.d.)
Asthma Medications: Maintenance versus Rescue
Rescue medications for asthma are fast and short acting. These medications are called inhaled short acting bronchodilators (beta agonists) and include albuterol and xopenex. These medications act quickly to relax the muscles that tighten during an asthma attack. The muscle relaxation allows air to move in and out of the airways again. It is important that anyone with asthma has a rescue medication on hand at all times. It is important to keep this medication with the child and to obtain refills before the medication runs out. If the child is at school their medication should be at school. Anyone responsible for caring for the child should know when and how to give the medication. (National Heart Lung and Blood Institute, n.d.) Children with asthma learn at a young age how they feel when they breathe and know when they need their medication. It is important to listen to the child. It is also important to follow the asthma action plan as it is a guide as to how often the medication can and should be given. It will also guide the family on when they should call the PCP or go to the emergency room for more specialized treatment.
Maintenance medications include corticosteroids such as pulmicort, beclomethasone and flovent, and leukotriene receptor antagonists such as singulair. (Allergy & Asthma Network, n.d.) The asthma guidelines state that those individuals having symptoms more than twice per week likely need to be on a maintenance medication. These medications are more focused toward prevention of symptoms. They will not help at the time of an asthma attack. When symptoms occur the rescue inhaler should be used. Often these maintenance medications are an anti-inflammatory or a corticosteroid. Anti-inflammatory medications help to reduce or prevent swelling in the airways. Corticosteroids help to decrease and prevent swelling in the airways as well as decrease mucus in the lungs. (Asthma and Allergy Foundation of America, n.d.) At times a corticosteroid may be given at the time of symptoms to be taken over a specific period of time. This is to relieve symptoms, but again it will not help at the time of an attack. It is very important that maintenance medications be taken as directed. If a daily dose is prescribed it is important to continue that schedule even when symptoms are not present. These medications are for prevention and they cannot prevent if they are not taken regularly.
Additional teaching points
Individualized for specific medication needed, for group sessions discussions on the routine drugs would be included.
Adverse effects of inhaled albuterol include increased heart rate and blood pressure, tremors, anxiety, palpitations, and throat irritation.
Adverse effects of oral albuterol include increased heart rate, anxiety, palpitations, headache, tremors, insomnia, muscle cramps, nausea, vomiting and dyspepsia.
Caution should be used in patients with a history of ischemic heart disease, seizures, diabetes or hypertension.
Extended release tablets and oral tablets are not recommended for children under 6 years of age.
Liquid albuterol is not recommended for children less than 2 years of age.
Advise families to discuss other medications including OTC meds with their PCP.
After all inhaled medications the patient should rinse out their mouth with water. (Aschenbrenner & Venable, 2009)
Adverse effects include headache, dizziness, and fatigue.
After inhaled medication the patient should rinse mouth with water.
Take daily as prescribed even when symptoms are not present.
Allergy & Asthma Network (n.d.). Asthma Medication Chart. Retrieved December 7, 2008, from http://www.aanma.org/pdf/ph_AsthmaMedicationChart.pdf
Aschenbrenner, D. S., & Venable, S. J. (2009). Drug therapy in nursing (3rd ed.). Philadelphia, PA: Wolters Kluwer Health / Lippincott Williams & Wilkins.
Asthma and Allergy Foundation of America (n.d.). Asthma Overview. Retrieved December 7, 2008, from http://aafa.org/display.cfm?id=8&cont=8 Burkhart, P., Rayens, M., Oakley, M. G., Abshire, D. A., & Zhang, M. (2007). Testing and Intervention to Promote Children’s Adherence to Asthma Self-Management. Journal of Nursing Scholarship, 39(2), 133-140. Retrieved November 29, 2008, doi:10.1111/j.1547-5069.2007.00158.x
Cicutto, L., & Ashby, M. (2007). The importance of a Community-Based Asthma Helpline. Journal of Asthma, 44(9), 705-710. Retrieved November 29, 2008, doi:10.1080/02770900701595568
Karch, A. M. (2009). 2009 Lippincott’s Nursing drug guide. Philadelphia, PA: Wolters Kluwer Health / Lippincott Williams & Wilkins.
Leyshon, J. (2007). Correct technique for using aerosol inhaler devices. [Electronic version] Nursing Standard, 21(52), 38-40.
McMullen, A., Yoos, H. L., Anson, E., Kitzmann, H., Haltermann, J. S., & Sidora-Arcoleo, K. (2007). Asthma Care of Children in Clinical Practice: Do Parents Report Receiving Appropriate Education? [Electronic version] Pediatric Nursing, 33(1), 37-44.
National Heart Lung and Blood Institute (n.d.). What Are the Signs and Symptoms of Asthma? Retrieved December 7, 2008, from http://www.nhlbi.nih.gov/health/dci/Diseases/Asthma/Asthma_SignsAndSymptoms.html
National Heart Lung and Blood Institute (n.d.). How is Asthma Treated and Controlled? Retrieved December 7, 2008, from http://www.nhlbi.nih.gov/health/dci/Diseases/Asthma/Asthma_Treatments.html
Texas Department of State Health Services (2008). The Burden of Asthma in Texas. Retrieved December 7, 2008, from http://www.texasasthma.org/attachments/wysiwyg/539/FastFacts.pdf
Trollvik, A., & Severinsson, E. (2005). Influence of an asthma education program on parents with children suffering from asthma. Nursing and Health Sciences, 7(3), 157-163. Retrieved November 29, 2008, doi:10.1111/j.1442-2018.2005.00235.x
Yoos, H. L., Kitzman, H., Halterman, J. S., Henderson, C., Sidora-Arcoleo, K., & McMullen, A. (2006). Treatment Regimens and Health Care Utilization in Children with Persistent Asthma Symptoms. Journal of Asthma, 43(5), 385-391. Retrieved November 29, 2008, doi:10.1080/02770900600710383