Asthma in Elementary School Children

The first time I saw the illness Asthma portrayed in a movie was in the 1985 film, The Goonies. In this movie the lead character, Mikey, suffers from asthma. Throughout the movie he is shown using his inhaler multiple times, but at the end of the movie, he throws his inhaler away because supposedly he no longer needs it. But for the millions of kids who saw that movie and suffered from Asthma, their reality was a different movie. Asthma was there to stay.

Though we have made progress in medicine towards controlling asthma, we do not have a cure. Today, Asthma continues to have an impact on school aged children. Our plan is aimed at the prevention of an asthma attack and reducing the incidence of asthma attacks in school aged children.

Asthma is a common lung disorder in which inflammation causes the bronchi to swell and narrow the airways, creating breathing difficulties that may range from mild to life-threatening. Symptoms include shortness of breath, cough, wheezing, and chest tightness. The diagnosis of asthma is based on evidence of wheezing and is confirmed with breathing tests. In an asthma exacerbation, the respiratory rate increases, the heart rate increases, and the work of respiration increases. Individuals often require accessory muscles to breathe, and breath sounds can be diminished. It is important to note that the blood oxygen level typically remains fairlynormal even in the midst of a significant asthma exacerbation. Low blood oxygen level is therefore concerning for impending respiratory failure (Mustafa &Shiel, 2012).

There are two types of asthma, Extrinsic (which is related to allergies) and Intrinsic (a non-allergic asthma). Extrinsic typically develops in childhood. Usually the child will have some type of documented allergies, with a strong family history of allergies. Along with the diagnosis of Asthma, the child may also have a combination of nasal allergies and or eczema. This type of asthma will usually disappear in early adulthood but has a high chance of returning later in their lives. Intrinsic asthma usually develops after the age of 30 and is not typically associated with allergies. Women are more frequently affected and many cases seem to follow a respiratory tract infection. Obesity also appears to be a risk factor for this type of asthma. Intrinsic asthma can be difficult to treat and symptoms are often chronic and year-round(Mustafa &Shiel, 2012).

Due to the fact that school aged children spend a majority of their day in a classroom, it is important that teaching is in place for the student, the parent and the school staff. As an asthma sufferer myself, the treatment back in the 1970's was a medication called quibron (which is now recognized as theophylline), tubs full of ice to break the fever and weeks of missed school. When my daughter was diagnosed with asthma, I found myself back in the world of the 1970's and it felt that some progression was made, but not enough to say that I felt comfortable with my daughter going to school on days when she'd had a bad night, or I could hear her wheezing while I was getting her dressed in the mornings for school.

The statistics for people living with asthma is overwhelming. According to the Center for Disease Control (CDC), the following report is being published:

• The number of people with asthma continues to grow. One in 12 people (about 25 million, or 8% of the population) had asthma in 2009, compared with 1 in 14 (about 20 million, or 7%) in 2001.
• More than half (53%) of people with asthma had an asthma attack in 2008. More children (57%) than adults (51%) had an attack.
• 185 children and 3,262 adults died from asthma in 2007.
• About 1 in 10 children (10%) had asthma and 1 in 12 adults (8%) had asthma in 2009. Women were more likely than men and boys more likely than girls to have asthma.
• About 1 in 9 (11%) non-Hispanic blacks of all ages and about 1 in 6 (17%) of non-Hispanic black children had asthma in 2009, the highest rate among racial/ethnic groups.
• The greatest rise in asthma rates was among black children (almost a 50% increase) from 2001 through 2009.

The challenges with the school aged child and asthma is that the diagnosis becomes more of a need for the community around them to be taught. There is more than one person to educate. As we know, information is processed and understood differently by all involved. How the person learns is based on what they know. School aged children are in the cusp of learning. They may not fully understand their physical limitations.Teaching and learning what triggers the asthma attack must be a priority in the education of the patient, the parent and the school staff.We recognized three steps that would help in the prevention and reduction of asthma attacks in the elementary aged child. The first step in asthma prevention is attempting to control the home environment. The second step would be to learn how to correctly use the inhalers and how to take the medications prescribed. The third step would be to enlighten and modify the child's school community.

In my daughters' case,we made changes in the home environment. We attempted to improve the air quality in the home and tried to reduce those allergens that triggered her asthma. We covered her mattress and all pillows with allergen and dust mite prevention covers. We did not have any pets, as she was allergic to the pet dander. She was also allergic to metals, all her pants I would buy with an elastic waist or if she had a button at the waist, I would paint the back of the button with a nail polish to keep her from having a reaction to the metal. No one could smoke in my home and if we went out to eat, it had to be a smoke free environment. Her room was kept as dust free as possible, no stuffed animals were allowed as they harbor dust mites. We knew that she was allergic to shrimp, so we stayed away from sea food.

When Samantha was about 12 years old, a physician overheard my conversation about Samantha's asthma, and he referred me to an old Asthma doctor in town. On our very first visit to his office, Samantha had a terrible night with her asthma. He did a PFT (pulmonary function test) in his office, we had never had one done before. When the results came back, he refused to let us go from the office. He said that Samantha was on the verge of respiratory failure and that we had to try to open her up or she would have to go to the hospital. After three nebulizer treatments, a shot of a corticosteroid, several inhalers and three more pulmonary function tests, we were finally allowed to be discharged home. He said that Samantha had learned how to compensate and that he guessed that Samantha was often in trouble, but that children were resilient, and they knew how to manage when their bodies were failing. He sent us home with a Peak Flow Meter, a chamber for her inhaler and new prescriptions for new inhalers and pills. It was the turning point we had been praying for. We finally found a doctor who understood what was wrong with her.

The third step would be the school environment. Unfortunately, since a lot of our schools are old, it would be safe to assume that our schools have issues with their air quality. Mold, Mildew, cockroach and rat droppings are triggers for asthmatics and these are commonly found in the child's school environment. I always kept a HEPA air purifier in the house and in my daughter's room to try to give her cleaner air. This could also be done in the child's classroom. Sitting with the teacher and the school nurse and creating a 1:1 learning environment, to review the child's triggers, symptoms and medications is also a necessity. H.R.2023 cites an act titled the "Asthmatic School Children's Treatment and Health Management Act of 2004. This act recognized asthma as a chronic condition that required life time, ongoing medical intervention. It allowed the school aged child to carry his or her rescue inhaler and epinephrine auto-injectors. With the proper documentation from the physician, a school is no longer allowed to interfere with the physician-patient relationship. My daughter graduated from high school in 2017, it wasn't until she was in 11th grade that she began to carry her own inhaler. Before this time, all medications, even with a doctor's prescription and the inhaler had to be left in the nurse's office. This became an issue when my daughter had after school sport activities and she needed an inhaler. This act needs to be enforced by the parents and it needs to incorporate by the schools. I sadly did not know that this act existed, but I don't believe that the school nurse was aware of this act either. We were lucky in some of Samantha's teachers, some were very proactive and helped in any way that they could. I was able to put together for Samantha a rescue bag that followed her thru 5th grade. Whenever she and another asthmatic student, Dominique, went on field trips, this rescue bag went with them. It contained instructions on how to give Benadryl and how to use the rescue inhaler. It contained my emergency contact information for me and her physician.

In an interview with my now 19-year-old daughter, Samantha, I asked her about her asthma and what could have been done to teach her and her schools more about asthma. She said that in third grade, that kids were kinder and that whenever she and a fellow student, Dominique were having issues with their asthma, it was often their fellow students that went to their teachers for help. She went on to say that if the adults, in the child's life would basically learn three things about a child with asthma, then the incidence of asthma would hopefully diminish in elementary school. "When a child says I can't breathe, or my throat is tight and feels like its closing or my cheeks feel hot or people say they are red. it is time to listen and act as the child is already in trouble. My daughter's reaction to the act passed in 2004 was also a surprise and brought tears to her eyes. Her best friend Dominique(at the age of 11) died from an asthma attack in her home, this became the wake-up call for all of us.

The target population iselementary school children who belong to the age group between six to eleven years. According to Bastable (2014), this group are "more realistic and objective, understands cause and effect, wants concrete information, able to compare objects and events and are subject-centered focus (p. 175). The teaching strategy as stated above is suitable as well as making the teaching session brief to avoid being bored and retaining less information.

With regards to this set of population, the learning theory that would provide the best learning experience would be the Cognitive learning theory. Cognitive learning theory "is widely used in education and counseling. (Bastable,p.72) This learning theory engages individuality and concentrates on the learner(s). The focus of Cognitive theory is patient driven and emphasizes the learner's goals and expectations and involves bothinternal and external dynamics. Various perspectives in Cognitive learning theory indicate much what goes on inside the learner. This theory incorporates gestalt principles and focuses on simple, clear explanation that settles their uncertainty and relates directly to them and their familiar experiences. (Bastable, p. 73)

Educating patients is a fundamental tool for improving patient health. Nursing educators will need to assess the "learners' needs, readiness, and styles of learning. (Bastable, p. 115). In addition to assessing the learner's readiness, objectives also needs to be established for the teaching. According to Bastable,"Objectives are short term in nature and should be achievable at the conclusion of one teaching session or usually within a matter of days following a series of teaching sessions. (Bastable, p. 425) Objectives include:

• After the education by the nurse educator, the learners will be able to describe asthma and its symptoms and disease process
• Upon completing the education, the learner(s) and/or their caregivers will recognize and describe signs and symptoms of an acute exacerbation of an asthmatic episode.
• Upon completing the education, the learner(s) and/or their caregivers be able to verbalize and explain when to appropriately administer asthma medication.
• Upon completing the education, the learner(s) and/or their caregivers will explain the provider's instructions for the correct dosage of the asthma medication.
• After watching the nurse educator demonstrate how to use the inhaler, the learner(s) and/or their caregivers will be able to return-demonstrate how to use inhaler correctly and spacer, if needed.
• After reviewing the Asthma Action Plan, the learner(s) and/or their caregivers will verbalize and understand the Asthma Action Plan.
• After teaching, learners and caregivers with be able to demonstrate when to seek emergency care or call 911.
• After the education, the school nurse will be provided with medication (if needed) as well as emergency information and instructions.
• Upon completing the education class, the learner(s) will verbalize symptoms of when to seek medical care from the school nurse.
• The teaching strategy for this group of population includes:
• Encouraging independence and active participation.
• Using logical explanation and allowing time for questions.
• Using analogies to make invisible processes real.
• Relating care to other children's experiences, comparing procedures.
• Establishing role models and using play therapy.
• Providing group activities.
• Using drawings, models, dolls, paintings, audio and video tapes.

The teaching session will be specific, simple, and 15-20 minutes in length for the learner(s) and/or their caregivers. Simple and clear content is best for the learning process/ program to avoid confusion by the learners.The teaching session will take place in a quiet, well-lit room to provide maximum teaching-learning process. The content will be up-to-date, relevant, and accurate for the learners. The learners' literacy skills will be evaluated by the nurse educator before the teaching process.

The teaching material to be used needs to be age appropriate and has to take into consideration the cognitive stage of this age (6 to 11 years) which is concrete operational as well as psychological stage (industry versus inferiority).Materials would include visual aids, models, printed materials, and medication equipment similar to the one the learner will use. The learners and/or their caregivers will perform return demonstration after the nurse educator has demonstrated the proper technique for the asthma medication. "Return demonstration is carried out by the learner in an attempt to establish competence by performing a task with cues from the educator as needed. (Bastable, p. 483). Providing hands-on materials and supplies promotes proper return demonstration for the learners and/or their caregivers. The learners and/or their caregivers will be provided with written instructional materials which help when the learner(s) go home or is the nurse is not available to answer questions or clarify information. Feedback from the learners would increase the results of permanent learning. In the end, "learning rests with the learner, but effective educators influence and guide the process so that learners advance in their knowledge, skills, perceptions, thoughts, emotional maturity, or behavior. (Bastable, p. 102) Four factors help with the learning process to become permanent. Those factors are organization of the learning experience, knowledge and skills need to be practiced, reinforcement, and finally evaluation and follow-up measurements of the learning process.

In conclusion, the learning-teaching process is changing and adapting, it is more important than ever for the nurse educator to adapt. "Because clients must handle many health needs and problems at home, people must be educated on how to care for themselves?”that is, both to get well and to stay well. (Bastable, p. 12) Evaluating the learner's literacy skills, computer skills, and willingness to learn is an essential piece for the learning-teaching process to be effective. Teaching elementary aged children the importance of their asthma disease, what to do in an acute situation, proper medication administration, and involving their family is crucial for the learners. "The key to effective education of the varied audiences of learners is the nurse's understanding of an ongoing commitment to the role of educator. (Bastable, p. 26). Evaluating the learning-teaching process is key to improving the learner's health.

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