Promoting Asthma Control in Children

Recommendation 1.0: All children identified, or suspected of having asthma, will have their level of control determined by the nurse.

Recommendation 1.1: During a nursing assessment of respiratory health, every child should be screened to identify those most likely to be affected by asthma. 

• Have you ever been told you have (your child has) asthma? 
• Have you (has your child) ever used a puffer/inhaler or any type of medication for breathing problems? Have you experienced any improvement with these medications?

Recommendation 1.2: If a child is identified as, or suspected** of, having asthma, the level of control should be assessed based on: 

• short-acting ß2-agonist use 
• daytime symptoms 
• night-time symptoms 
• physical activity 
• absence from school/work 
• exacerbations 

** If suspected of having asthma, further evaluation by a physician is required.
 

Recommendation 1.3: For children identified as potentially having uncontrolled asthma, the level of acuity needs to be assessed by the nurse and an appropriate medical referral provided (i.e., urgent care or follow-up appointment).

Recommendation 2.0: Nurses will understand the pharmacology of medications used to treat asthma in children. 

Recommendation 2.1: Nurses will be able to discuss the two main categories of asthma medications (controllers and relievers) with the child and their family members/caregivers, tailoring information for the developmental age of the child. 

Recommendation 2.2: All children with asthma should have their inhaler/device technique assessed by the nurse at each visit to ensure accurate use, as well as appropriateness of device for the developmental level of the child. Children with sub-optimal technique will be coached in proper inhaler/device use or switched to a more appropriate delivery device/system.

Recommendation 2.3: Nurses will be able to assess for potential barriers to asthma management. The nurse will be able to offer strategies to meet families’ needs and support them in overcoming issues leading to treatment failure.

Recommendation 3.0: The nurse will provide asthma education, in collaboration with the health care team, as an essential part of care. 

Recommendation 4.0: Child/family knowledge of asthma should be assessed by the nurse at each patient contact. Asthma education should be provided when knowledge and skill gaps are identified. 

Recommendation 4.1: Tailor asthma education to the needs of the child and family by being developmentally appropriate, sensitive to cultural beliefs and practices, and by using a variety of teaching methods (e.g., video, pamphlets, websites, group, role playing, problem-solving). 

Recommendation 5.0: The nurse can use a structured framework to build both the child’s and family’s knowledge of asthma and self-management skills by providing basic asthma education. A partnership between the nurse, child and family is important to engage the child and family in an interactive educational process.

Recommendation 6.0: All children will have an individualized asthma action plan for guided self-management, based on the evaluation of symptoms, with or without peak flow measurements, developed in partnership with a health care professional. 

Recommendation 6.1: The action plan must be reviewed, revised and reinforced in partnership with the parent/caregiver, child and health care professional during every contact. The nurse will coach the parent to act as an advocate for their child, ensuring that the action plan is kept up to date.

Recommendation 7.0: The nurse should facilitate follow-up assessments and education to achieve and maintain control of asthma for the child diagnosed with asthma. 

Recommendation 7.1: The nurse will determine the child’s primary care asthma management provider by asking “who do you see for your asthma management?” 

Recommendation 7.2: Nurses should advocate for a referral to an asthma specialist Level IV (respirologist, allergist, paediatrician, Certified Asthma Educator, etc.) for the following:

• frequent visits to the emergency department;
• poor understanding of asthma self-management;
• symptoms are not responding to usual treatment;
• and/or uncertainty of diagnosis. 

Recommendation 7.3: Nurses should advocate for referral to an asthma education program and/or link to community resources, if available.

Recommendation 7.4: Nurses should advocate for no exposure to environmental tobacco smoke.

Recommendation 7.5: Nurses will refer youth or parents/caregivers to tobacco cessation programs, if indicated.

Recommendation 8.0: Nurses working with children with asthma must have the appropriate knowledge and skills to: 

• identify the level of asthma control; 
• provide basic developmentally appropriate asthma education; and 
• identify the need for follow-up with primary care provider and/or community resources.

Recommendation 9.0: Organizational leadership must maintain a commitment to best practice guideline implementation. 

Recommendation 9.1: Organizations must maintain a commitment to sustain the healthy work environment required to support guideline implementation:  

• a critical mass of nurses educated and supported in guideline implementation;  
• care delivery systems and adequate staffing that support the nurses’ ability to implement these guidelines; and
• a sustained commitment to evidence-based practice in paediatric asthma care.

Recommendation 9.2: Organizations must promote a collaborative practice model within a multidisciplinary team to enhance asthma care. This approach must include all health care professionals and community caregivers involved with the child. 

Recommendation 9.3: Organizations need to plan and provide appropriate material resources to implement these best practice guidelines. Specifically, they must have: 

• placebos and spacer devices for teaching; 
• sample templates for action plans; 
• educational materials; 
• documentation tools 
• resources for child/family and nurse education;
• peak flow or other monitoring equipment, when indicated;
• in-patient materials/ programs

Recommendation 9.4: Organizations are encouraged to develop key indicators and measurements that will allow them to monitor the implementation of the guidelines, the impact of the guidelines on optimizing quality patient care, as well as any efficiencies, or cost effectiveness achieved. 

Recommendation 10.0: Nursing best practice guidelines can be successfully implemented only where there are adequate planning, resources, organizational and administrative support, as well as appropriate facilitation. Organizations may wish to develop a plan for implementation that includes: 

• An assessment of organizational readiness and barriers to education. 
• Involvement of all members (whether in a direct or indirect supportive function) who will contribute to the implementation process. 
• Dedication of a qualified individual to provide the support needed for the education and implementation process. 
• Ongoing opportunities for discussion and education to reinforce the importance of best practices. 
• Opportunities for reflection on personal and organizational experience in implementing guidelines. 

Recommendation 11.0: Government agencies responsible for the allocation of funding must recognize the critical role of a seamless continuum of care in promoting asthma control in children. This must include recognition and funding for the following: 

• health promotion activities provided by Public Health Nurses in such venues as schools; 
• acute care provided by nurses as part of health care teams in hospitals and community physician offices; and 
• long-term care, provided by community health nurses in family homes. 

Recommendation 12.0: Nurses should advocate for the promotion of optimal asthma care for children and families affected by asthma.