Lori zinck.doc

STUDENTS WITH ASTHMA:
LEVELS OF UNDERSTANDING AND TREATMENT ADEQUACY
Background
As a pediatric nurse for over twenty years, I have worked in many different health care settings including hospitals, clinics and now the public schools. One of the most frequent chronic illnesses that I have encountered is asthma. In the Madison school district, 2,288 students have the diagnosis of asthma; at Leopold Elementary School there are 42 students with asthma. Every day in school health office and at other school sponsored Healthcheck clinics, I see students who require assessment of their asthma symptoms and who frequently require asthma medication. I also see many students that are not receiving the appropriate treatment for their symptoms. This has a negative impact on school performance due to frequent absences or to the student’s inability to participate fully when symptoms are present. Asthma is a chronic inflammatory disease of the airways. It affects approximately 10%, or more than 4.8 million, of children living in the United States (Center for Disease Control and Prevention, 1999). Over the last two decades, the incidence of asthma has increased by 160% and death rates have more than doubled. The rate of emergenc y room visits and hospital admissions for children with asthma has also increased dramatically. The morbidity and mortality rates are especially high for African American children and children living in poverty I recently interviewed a mother and two of her children who had lost a 13 year old family member to asthma four years ago. Understandably, the family was devastated. The mother offered a great deal of insight into the “hows” and “whys” of this tragedy. She cited complicated family and home issues, a lack of understanding of the severity of his symptoms, and inappropriate medications, as factors contributing to her son’s death. A greater understanding of the pathophysiology of asthma has led to more effective treatment options over the last decade. With proper diagnosis and management, asthma can be well controlled. In 1997 The Guidelines for the Diagnosis and Management of Asthma, a very comprehensive clinical practice guide aimed at achieving optimal asthma control, was issued by The National Heart, Lung, and Blood Institute/National Health Institute. These guidelines recommend classifying the level of asthma severity as mild intermittent, mild persistent, moderate persistent, and severe persistent based on the intensity and frequency of symptoms (see Table 1). Effective management and specific pharmacologic therapy is based on the level of Classification of Asthma Severity*
Symptoms**
Nighttime Symptoms
Lung Function
Severe Persistent
Moderate
Persistent
• Exacerbations > 2 times/week • Symptoms > 2 times/week but < 1 Mild Persistent
Mild Intermittent
** Clinical features before treatment. The presence of one of the features of severity is sufficient to place a patient in that category. An individual should be assigned to the most severe grade in which any feature occurs. The characteristics noted in this figure are general and may overlap because asthma is highly variable. Furthermore, an individual’s classification may change over time. Patients at any level of severity can have mind, moderate, or severe exacerbations. Some patients with Intermittent asthma experience severe and life-threatening exacerbations separated by long periods of normal lung function and no symptoms. *National Asthma Education and Prevention Program, National Institutes of Health, National Heart, Lung, and Blood Institute. Guidelines for the Diagnosis and Management of Asthma. US Dept of Health and Human Services. Individuals diagnosed with mild intermittent asthma can usually manage their symptoms with quick relief or bronchodilator medications. The most commonly used quick relief medication is inhaled Albuterol, a short acting beta2–agonist, which relaxes smooth muscle and opens the airways. It is recommended that people with persistent asthma, mild, moderate, or severe, receive daily long-term control or maintenance medication. The most effective long-term controllers are those with anti- inflammatory effects that diminish chronic airway inflammation and airway hyper-responsiveness. The most commonly prescribed long-term control medications are inhaled corticosteroids used alone or in combination with inhaled long acting beta2–agonist, oral leukotrienes modifiers (Lazarus and Janson, 2002), and for more severe symptoms and exacerbations, oral systemic corticosteroids. In spite of these comprehensive guidelines and the effective treatments that are available, many children continue to have poorly controlled asthma. Underestimating the severity of symptoms and underuse of daily maintenance mediation is associated with poor asthma control (Halterman, 2002; Skoner, 2001). Treating Asthma in Adults and Children (ages 5 years and older)*
Long term Control – Daily
Quick Relief
• Inhaled short acting beta2-agonists as Severe Persistent
• Oral systemic corticosteroids for more • Inhaled corticosteroids (med dose) • Inhaled short acting beta2-agonists as • Oral systemic corticosteroids for more Moderate
Persistent
• Inhaled long acting beta2-agonists
• Consider oral leukotriene modifier
• Inhaled corticosteroids (low dose) OR • Inhaled short acting beta2-agonists as
• Oral systemic corticosteroids for more Mild Persistent
• Consider oral leukotriene modifier • No daily medication • Inhaled short acting beta2-agonists as • Oral systemic corticosteroids for more Mild Intermittent
• Using Inhaled short acting beta2-agonists > 2/week, may indicate need to initiate long-term control therapy. The NHLBI recommends two pharmacotherapeutic approaches, both enlisting the stepwise approach. One approach entails initiating therapy appropriate to asthma symptom severity at the time of the initial evaluation. If the patient does not achieve control, step-up the drug doses or add other drugs to the regimen. The second approach entails initiating therapy at a higher dose and, perhaps, adding a second drug class to achieve rapid control. Then, step-down the drugs to a lower dose that still maintains long-term control. A rescue dose of oral systemic corticosteroids may be needed for exacerbations at any level. *National Asthma Education and Prevention Program, National Institutes of Health, National Heart, Lung, and Blood Institute. Guidelines for the Diagnosis and Management of Asthma. US Dept of Health and Human Services. A lack of understanding about asthma is also a ma jor factor related to poor asthma control and lack of appropriate treatment (NHLBI, 1997; Skoner, 2001). According to the national guidelines, education represents one of the four components of effective asthma management. Learning to live with asthma requires skills such as identification and avoidance of triggers, medication use, monitoring symptoms, and inhaler and peak flow techniques. Evidence suggests that when people understand more about their asthma, adherence to treatment improves. (Valeros, Kieckhefer, and Patterson, 2001). Children participating in asthma education programs, report feeling better about their ability to manage their symptoms (Valeros et al, This year I have been involved in two different asthma education projects. Six Leopold students have participated in an asthma study at school, which has been conducted by The Dean Foundation for Health, Research, and Education. The purpose of this study is to evaluate the effectiveness of an interactive computer-based game, “Air Academy: The Quest for Airtopia” (1999, Merck and Co., Inc.), designed specifically as an asthma educational tool for children 6 to 12 years old. The final phase of the study is in process. The second project is the result of the school district’s collaborative contract with Group Health Cooperative of Southern Central Wisconsin (GHC). The goal of the GHC project was to maximize the number of asthma patients on appropriate maintenance medications and to minimize the number acute care visits. The primary focus of the project was to link students with their primary provider in cases where asthma follow-up was known to be less than optimal and to assist the family in implementing an ongoing treatment plan. The secondary focus was asthma education. As the district nurse assigned to the GHC project, I facilitated five separate educational groups for students at four different schools. As I contemplated my CAR project, I began to think about these educational sessions as an opportunity to explore some of my questions about asthma. I wanted to gain information regarding students’ general knowledge of asthma and the effectiveness of my teaching intervention. In addition, I wanted to assess students’ asthma symptoms and the appropriateness of their current medications. These were my research How well do students understand their asthma?
Does an educational intervention increase students’ understanding of asthma?
Are students receiving appropriate treatment based on their asthma symptoms?
Students with asthma in grades 4th through 8th were recruited by school nurses at Lincoln Elementary, Cherokee Middle and Hamilton Middle Schools to be part of an asthma educational group. Students identified by GHC as having asthma were targeted, as well as others non-GHC students who it was thought would benefit from the educational intervention. The study consisted of 24 students, 12 (50%) male and 12 (50%) female. The majority of the students (17, 70.8%) were African American, five (20.8%) were White, and two (8.3%) were Asian. Most of the students (22, 92%,) came from low- income families, and almost all were known to have some form of insurance, primarily Medical Assistance. Students participating in the Dean Foundation study did not take part in this study. There were four separate groups, each with four to eleven students. Each group met for three or four, 30-45 minutes sessions. The sessions were all held within the school and took place during the students’ lunchtime. Pizza was provided during the last session; at Hamilton pizza was provided at all sessions. The school nurse and myself facilitated the groups. The curriculum was developed using a variety of resources including the Open Airways for Schools Program (American Lung Association) and educational materials from University of Wisconsin Children’s Hospital, Group Health Cooperative, and Glaxo Pharmaceuticals. The following Parent letter – peak flow use and asthma An asthma assessment was given to the students at the beginning of the first class to assess their current level of understanding and to gain information about their asthma symptoms, medications, treatment, and general quality of life (see appendix A). An asthma quiz was given to each student to estimate their knowledge of asthma and its management (see appendix B). The same quiz was given at the completion of the last class to evaluate the effectiveness of the educational intervention, and to see if levels of understanding had increased. In addition, medical records of six study participants who were GHC-MA members were reviewed to obtain additional data regarding their asthma diagnosis and management. The asthma assessment tool was developed for asthma teaching purposes at weekly health check clinics. The quiz questions were developed from asthma teaching materials and modified from test questions that accompanied the “Air Academy: The Quest for Airtopia” educational program used in the Dean Foundation study (1999, Merck and Co, Inc.). Most of findings in this report were based on the information gathered in the initial asthma assessment I. How well do students unde rstand their asthma?
Almost all students could identify at least one symptom of their asthma and at least one trigger. Almost two thirds were able to name their medication(s), and describe accurate use (see Table 3). Student who were taking more than one medication for their asthma (one or more long term controllers, as well as quick relief medication) were also more aware of appropriate usage and were able to demonstrate a greater understanding of peak flow meter use. These findings were based on information reported by students in the initial asthma assessment. The following results support the findings regarding students’ understanding of asthma symptoms, • 23 (96%) students were able to correctly identify at least one of their asthma symptoms. The most common responses were “chest hurts”, ”start to cough”, and “hard to breathe”. • 22 (92%) could name the things that triggered their symptoms. The most common response was “running”, or an equivalent such as “soccer”; others mentioned “when I get a cold”, “allergies”, “smoke”, “cold weather”. • 15 (62.5%) were able to name their medications (at least phonetically, e.g. “Singwar” and “Senglar” were assumed to be Singulair). Four (16.6%) indicated “meds”, “pump”, or “inhaler” and were not given credit for a correct response. Four (16.6 %) responded with “no”, or “I don’t know”, and one (4.2%) recorded non-asthma medications (see Table 3). • 14 (58.3%) were able to state the correct use of their medication (see Table 3). For example they may have indicted that Albuterol was taken “only when needed” or that Flovent was taken twice every day. Other responses did not indicate a clear understanding of the correct use of the medication listed. An indication that Flovent was used “only when needed” was not considered a correct response. Flovent is used as a long-term control and is prescribed • There was a positive correlation between the use of multiple medications (such long term controllers and antihistamines, in addition to quick relief medications), and the students ability to state the correct use of all of their medications (r = .51, p < .01). Medications
Medications and peak flow usage as reported verbatim by students (Last column indicates medication prescribed for six GHC study participants according their medical records.) • Medications reported by students were compared with medications prescribed by providers according to GHC records for six of the study participants (see Table 3). Two students had been prescribed Flovent, but the student did not indicate this. One of these students had also been prescribed an oral steroid according to the GHC records, but not indicted by the student. • Only eight indicated that they understood the correct usage of a peak flow meter and were II. Does an educational intervention increase students’ understanding of asthma?
Results indicate that students general understanding about asthma and its’ management increased slightly following asthma education classes. This finding was based on pretest and posttest scores on the asthma quiz (see Appendix B for percentage of correct responses to each quiz question). However, only half of the original students completed the posttest due to time constraints, attrition and non-attendance. • The average score on the pretest was 71%. All students (24) completed the pretest.
• The average score on the posttest was 84%. Only 11 students completed the posttest.
• Attendance at the asthma classes was not consistent due to absences, suspensions, and
decreased interest. Often students were late because they forgot or they had to get their lunches. One student became homeless during the course of the class and was not attending • It was difficult for the fourth and fifth graders to complete the “paper work” (the asthma assessment and quiz) during the initial class; I had planned to go over the forms out loud and as a group, but students arrived at varying times. • The pizza became a source of distraction for some of the sixth graders. But probably the greatest distraction and reason for poor attendance for all of the age groups, was that fact that recess followed lunch and they were anxious to get to recess. III. Are students receiving appropriate treatment based on their asthma symptoms?
Results from this study indicate that 67% of the students had symptoms consistent with persistent asthma (mild to severe), but only 37.5% were receiving daily long-term control medications. In order to evaluate the appropriateness of medications and treatment, an asthma severity classification was estimated for each student. Results that summarize severity level classifications and medications follow. Also see tables 4 and 5. For the purposes of this study, severity levels were estimated using the NHBLI criteria (see Table 1). These levels were compared with school nurse ratings, GHC nurse ratings, and students’ ratings of their asthma severity. For comparisons see Table 4. NHBLI Classifications (See Table 1) • Students were asked to report how often in the past four weeks, they had experienced asthma symptoms of coughing, noisy breathing, shortness of breath, chest tightness, waking with symptoms during the night and early morning, and symptoms with physical activity. Based on the frequency that students reported these symptoms, a severity level was estimated as • The mean NHLBI severity rating score for the group was 2.20 based on a 4-point scale, or 2.75 when converted to a relative score based on a 5-point comparison scale. • In addition, school nurses who were very familiar with each student were asked to estimate the severity of the student’s asthma, on a scale from 1 to 5, with 1 being mild and 5 being severe. The mean score assigned by school nurses for the group was 2.88. School nurses scores were positively correlated with the NHLBI severity scores (r =. 52, p <.05). • The GHC nurse who oversees the project reviewed the medical records of six students who received medical care from GHC. A severity rating between 0 and 6 was estimated based on types of medication prescribed; number of refills on medications; number of clinic, acute care, and emergency room visits; and overnight hospitalizations for asthma. The mean score assigned by the GHC nurse was 1.83, with a relative score of 1.31 (based on a 5-point scale) and a range of 0-3. The GHC nurse scores did not correlate with the NHLBI scores or the • Students were asked to rate their perception of the severity of their asthma on a scale from 1- 5, with 1 being mild and 5 being severe. The average rating was 3.56 with a range from 1-5. There was a slightly positive correlation between student’s perception of their asthma severity and their NHLBI score (r = .38, p < .10). There was no relationship between students’ perception of their asthma severity and the scores assigned by the school nurses or the GHC nurse. In general, students rated themselves as having more severe asthma than their symptoms indicated or than the school nurse, or the GHC nurse perceived. Effects Of Asthma on Daily Living • 19 (79%) students reported that their asthma kept them from doing thing like playing sports, participating in physical activities, and doing things with friends or family. • 14 (58%) students reported that they miss school due to their asthma. The days reported missing so far this year ranged from 1.5 to 7. One student simply stated “a lot”. • School attendance records were checked and it was found that the average rate of attendance for students in the study was 89.8% or 10 days of absence. This ranged from 99.6% (or .5 absent days) to 81.25% (or 25.5 days.) These figures are slightly lower than the overall MMSD district attendance rate of 93.9% or 8.3 days of absence (for the school year 2000- • Students in the study had a lower rate of attendance when compared with the MMSD district average. However, their rate of attendance did not appear to be related to any of the other study variables, such as levels of understanding, asthma severity, or adequate treatment. Attendance issues have been explored in some depth by the MMSD and are related to many complex issues that are beyond the scope of my action research project. Severity Ratings
Comparisons between NHBLI severity classifications (based on students’ self-reported symptoms), school nurse severity ratings, GHC nurse severity ratings, and students’ self-rating for asthma severity. *Relative scores converted to a 5 point scale for comparison • 22 (92%) students indicated that they used quick relief medications or short acting beta2 – agonists in the form of Albuterol (both inhaled and nebulized). • 9 (37.5%) students stated that they used a long term controller medication (inhaled corticosteroids or oral leukotrienes). This may be somewhat higher given that two students did not acknowledge use of Flovent, which had been prescribed by GHC providers for daily maintenance. (Again medical records were only reviewed for six students.) See Table 5 • 3 (%) used a long acting beta2 –agonists in addition to another long-term controller. • 1 (4.6%) student reported taking oral corticosteroids when needed. • 9 (37.5%) indicated use of a peak flow meter and were able to state their best recording. One student reported only using her peak flow at school. Severity classification vs. medications
quick relief medications (short acting beta2 agonists) long-term daily control medications (inhaled corticosteroids or oral leukotriene modifiers) long-term daily control medications (long acting beta2 agonists, not recommended to be used without inhaled corticosteroids or leukotrienes modifiers) antihistamines/allergy medications Discussion
The findings in my study were based on self-report measures of children. I am not familiar with the validity of self- report for children in this age group. They may lack an awareness of their own asthma symptoms, such as coughing at night, and their recollection of specific symptoms over a month’s time may be limited. This data was not compared to parental I was pleasantly surprised by how well many of the students understood aspects of their asthma and its treatment. Almost all could identify at least one symptom of their asthma and at least one trigger. Almost two thirds were able to name their medication(s), and describe accurate use. I also found it interesting, and reassuring that students who were taking more than one medication for their asthma (one or more long term controllers, as well as quick relief medication) were also more aware of appropriate usage. Several listed up to four medications with clear indications of when and how often they were taken, and how many pills or puffs. These same students also demonstrated a greater understanding of peak flow meter use. This was likely the result of more consistent medical care, an appropriate asthma plan based on treatment guidelines, and education about asthma. From these results, it appears that MMSD students in late elementary and middle school age have a good understanding of their asthma and it’s treatment, and that an educational intervention resulted in a slight increase in student’s level of understanding. I think it is important to continue to direct educational efforts towards students. However, conducting classes during the school day is somewhat problematic. Pulling students out of regular instruction was not considered and lunch/recess time provided a very limited amount of time and reluctance on behalf of students to miss out a very social part of their day. I’m not sure how after school classes would be attended. Providing instruction to one or several students may provide greater flexibility in scheduling and be more manageable. Alternative approaches to asthma education in school that would involve parents and community health care providers could be explored. One idea may be to have an asthma night at school for students and their families conducted by providers and school nurses. Services offered might include education, consultation, assessment of symptoms, diagnostic/spirometry testing, and possibly, treatment The severity classifications and ratings estimated in this study, which were based on the national guidelines may have limited value for several reasons. As noted, they were calculated based on symptoms reported by students and may not be entirely accurate. It would have been helpful to compare these ratings to parental perceptions. Also, medical records were examined for only one quarter of the study participants. Further investigation into prior and current health care diagnosis and recommendations may have provided additional information. Severity classification ideally should be determined prior to the initiation of any treatment. Most of the students in the study were receiving some type of asthma therapy. Several students who appeared to be receiving appropriate treatment (i.e., use of quick relief and long term controller medication, knowledge of peak flow usage) still fell into the severe persistent classification. The questions then become more involved. Are these accurate measures of symptoms and severity? Are students adhering to the prescribed treatment plan? Are they receiving adequate follow- up? Do their medications need to be changed or increased? Is their technique of using inhalation devices adequate? The method of severity classification that I used may not be precise, however it was more convincing to find that the severity ratings were validated by school nurses. School nurses have close contact with the students and are often able to assess their symptoms over a fairly lengthy period of time. They are also familiar with other school and family issues which may be related to asthma symptoms and treatment needs. It would have been interesting to explore the current and past interventions by school nurses and their levels of involvement with each study At first I was surprised that there was no relationship between the NHLBI/school nurse severity ratings and those estimated by the GHC nurse, which were based on student’s medical records. This may be explained, in part, by the fact that only six comparisons were made; correlation would need to be extremely high to reach levels of statistical significance with such a My action research results supported studies revealing that children are not receiving adequate asthma treatment based on the severity of their symptoms. While two thirds of the students fell into the mild persistent to severe persistent asthma classifications, only approximately one third reported use of long term maintenance medication. I believe multiple One contributing factor may be related to health care providers’ failure to adhere to treatment guidelines. As I attempted to estimate the students’ level of severity, I found the guidelines very complicated and time consuming to apply. Providers may lack familiarity with the guidelines, or they simply may not have (or take) the time to thoroughly assess symptom frequency and severity. This may be especially true in acute care settings whe re children with poorly controlled asthma are often treated. One school nurse shared her frustration related a study participant's frequent asthma symptoms over a period of six months. The student was repeatedly diagnosed with “bronchitis” and given an alb uterol inhaler. The parent was very frustrated because she felt the health care providers were not listening to her or her children (two of her girls have asthma). The mother asked an urgent care physician what he thought about prescribing a steroid inha ler, but was told it wasn’t needed. After five days of wheezing, the school nurse talked with the urgent care physician about prescribing oral steroids; he was then willing to prescribe a steroid, but only the inhaled form. This student eventually saw a pediatrician who further evaluated her symptoms and she began treatment with the appropriate Family’s health care seeking behaviors may also contribute to difficulty in applying treatment guidelines. Parents may not seek timely medical attention for their children when asthma symptoms are present and they may not share the prevalence of these symptoms. This may be due to parents not recognizing or understanding asthma symptoms or it may demonstrate how families acclimate to the harmful effects of asthma on their child’s health and their everyday lives, without realizing that better treatment options exist. Also, they may not value or understand the importance of periodic monitoring and regular follow-up, which is an essential component of effective asthma management. I also believe that fragmented health care and lack of consistent providers contribute to the outcome of poor asthma control. Fragmented health care may result when children are seen in emergency rooms and acute care settings, rather than by a primary provider. As a result of complicated insurance issues or lack of insurance, families may also find it difficult to obtain regular medical care. Most of the students in the study group were receiving medical assistance. A different school nurse reported that a student in our group was having difficulty refilling his prescription for Albuterol. His medical care, under medical assistance, had been reassigned to a completely different managed care organization where he had never been seen and that had no record of his previous health conditions. The reassignment had occurred because the parent had failed to complete a form that had been mailed to the family. When families can not establish a medical home with providers who are familiar with their child’s overall health status and who have access to their medical history, the likelihood of receiving an accurate diagnosis with School nurses can play a major role in minimizing the effects of asthma on a student’s educational performance and general quality of life by assuring that students are receiving appropriate care and treatment and by providing education. Direct communication between school nurses and health care providers to exchange information and concerns is essential. The development of a standardized form or a communication tool may provide a more efficient and effective method of sharing assessments and observations. Exploring and establishing consistencies in school health offices regarding asthma symptom assessment and administration of asthma medications would be helpful in refining asthma care in the school setting. School nurses should continue to explore creative approaches to educating both parents and students Health care organizations have recognized the valuable connections that school nurses have with students and families, as well as their role as health care educators. Through collaborative efforts, Group Health Cooperative of Southern Wisconsin and MMSD school nurses have linked students with primary providers and treatment plans have been implemented. Results of the Dean Foundation study may provide information regarding effective teaching strategies for use by school nurses. Expanded collaboration and joint ventures with local health care providers may enhance our ability to help students and families effectively manage their Reflections on the action research process
When I first heard about the action research class I was very interested. I was familiar with the research process from my own experiences in graduate school and through completing my own thesis. However I was intrigued with the idea of doing something on a smaller scale and with researching something relevant to my own everyday practice. I was also excited about the opportunity to be working with other school nurses in the district. I had many ideas about what I wanted to research, but I hadn’t really thought out the feasible and practical aspects. Focusing on asthma seemed very natural since it was something that I was especially interested in, and because conducting asthma classes was already a part of my GHC/healthcheck assignment. A strong question in my mind from the very start was related to the lack of adequate treatment for children with asthma and also, children’s understanding of their asthma symptoms and treatment. Measuring pretest and post-test levels of understanding following the asthma education classes seemed like an obvious and easy question to add. I was able to formulate my questions fairly quickly and the rest seemed to fall into place. I had already developed the curriculum that I planned to use, as well as the asthma assessment tool. The asthma quiz was easy to and fun to develop; I basically modified questions from several other sources of asthma education. Other school nurses took the task of recruiting the students in their schools and planning the logistics of when and where classes would be held. However, when I began to analyze the data and write up my report, the project suddenly took on a life of it’s own (and possibly mine for a short time). I had gathered so much interesting information and it all seemed relevant. Every time I tried to narrow my focus, I felt like I was missing the big picture. I knew from a practical standpoint, that I couldn’t possibly use all the data and information that I had collected, but it was frustrating for me to disregard data that was staring at me from the page and seemed so pertinent to my research questions. In retrospect, it would have been much more manageable if I had limited my study to either the first two questions or the third question. I also hadn’t anticipated that determining severity levels for the students would be so complicated. I think I got a little carried away with that process. The problems that I encountered were largely due to my own lack of vision. I remember the instructors and another classmate asking which question I was going to research, but I thought it made more sense to do it my way. I also became completely engrossed in analyzing the data and looking at the relationships among all the variables. The project became somewhat labor intensive at that point, but just the same, I was fascinated with the possibility of these relationships and with the statistical analysis. It was also amazing to learn that I could do so much with my own basic Microsoft programs on my own home computer. All in all, the class was a fun learning experience. The instructors (Cathy and Kathy) provided us with guidance and direction, but mostly challenged us to look at why we were asking the questions and how we would use the information that we learned. They were always very positive about our accomplishments. Bibliography
1. Divertie, V. Strategies to Promote Medication Adherence in Children with Asthma. The American Journal of Maternal and Child Nursing. 2002; 27:1; 10-18. 2. Center for Disease Control and Prevention. Self-reported asthma in adults and proxy- reported asthma in children-Washington, 1997-1998. MMWR Morbidity and Mortality Weekly Report. 1999; 48:40; 918-920. 3. Halterman, J. Asthmatic Children May Often Be Undermedicated. Archives of Pediatric and Adolescent Medicine, 2002; 156:141-146 4. National Asthma Education and Prevention Program, National Institutes of Health, National Heart, Lung, and Blood Institute. Guidelines for the Diagnosis and Management of Asthma, Expert Panel Report 2. Washington DC, US Dept of Health and Human Services, 1997. 5. Lazarus, S.C.; Janson, S. Where Do Leukotriene modifiers fit in asthma management? The American Journal of Primary Health Care. 2002; 27:4; 19-29. 6. Skoner, D. Why we must do a better job controlling asthma. Contemporary Pediatrics. 7. Valeros, L.; Kieckhefer, G.; and Patterson, D. Traditional Asthma Education for Adolescents. Journal of School Health. 2001; 71:3; 117-119.
APPENDIX A
_________Birth date: School:________________ l 1. When did you get asthma? ___________________________________________________________ 2. How do you know that your asthma is acting up? ________________________________________________________________________________ ________________________________________________________________________________ 3. What things “trigger” or start your asthma? ________________________________________________________________________________ ________________________________________________________________________________ 4. In the past 4 weeks, how often did you experience the following ASTHMA symptoms: Waking with symptoms early in the morning 5. Do you ever miss school due to your asthma? _____yes; _____no If yes, approximately how many days/year? ______ 6. Does your asthma ever keep you from doing things? (like playing sports, physical activity, doing things with your friends or family, going to work) ? _____yes; _____no 7. How often do you visit a doctor for your asthma? ________________________________________ 8. Have you ever gone to the hospital or emergency room for your asthma? _____yes; _____no If yes, approximately how many times? ________ 9. Have you ever been hospitalized over night for your asthma? _____yes; _____no 10. How often do you visit the school health office for you asthma? _____________________________ 11. What medications do you currently take? 12. Do you use a peak expiratory flow meter? ____yes; ____no How often or when? _____________________________________________ What is your best reading? ________________________________________ 13. On a scale of 1 – 5, how helpful is your medication? 14. On a scale of 1 – 5, how well controlled do you think your asthma is? 15. On a scale of 1 – 5, how well do you think you understand your asthma and it’s treatment? 16. On a scale of 1 – 5, how severe do you think your asthma is? 17. On a scale of 1 – 5, how worried or anxious do you feel about your asthma? 18. Do you have a written asthma plan from your doctor or health care provider? ___yes; ___no APPENDIX B
Percentage of correct responses on each quiz question ASTHMA QUIZ
People who have asthma may be
a) professional athletes
c) adults
d) all of the above
All of the following things may “trigger” or start an asthma
episode except
b) playing computer games
c) cats and dogs
d) a cold or viral infection
When your airways become smaller
a) less air gets into and out your lungs
b) more air gets into and out your lungs
c) no air gets into or out your lungs
d) your lungs turn into marshmallows
All of the following may be symptoms of asthma except
a) coughing
b) noisy breathing
c) stomachache
d) feeling of chest tightness or pain
e) feeling short of breath
Goals of your asthma treatment should include
a) avoiding the triggers which cause your symptoms to
b) knowing how to use your medicine properly
c) sleeping through the night
d) knowing what to do in an emergency
e) all of the above
When should you use your quick-relief inhaler?
a) never because it is bad for you
b) every four to six hours every day
c) if you feel short of breath, chest tightness, wheezing, coughing, or
before exercise
d) only after your doctor or nurse has examined you and instructs If the recommended number of puffs of your quick-relief inhaler a) you probably don’t have asthma
b) you should keep repeating it until it helps
c) you should talk to an adult or your doctor or nurse
d) you should get a bigger inhaler
Using your controller inhaler is like brushing your teeth
a) daily use will cure your asthma
b) daily brushing helps prevent cavities
c) it makes your teeth whiter
d) daily use helps prevent asthma symptoms
If you have frequent asthma attacks, it means that
a) you have really bad asthma
b) you are eating too much candy
c) your medications may need to be changed
d) you need to sleep more

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