PEDIATRIC ASTHMA INPATIENT CARE MAP

DATE PATIENT PEDIATRIC ASTHMA INPATIENT CARE MAP DOB HSC NO. PHIN Approved by the Winnipeg Regional Health Authority This Care Map is to be used as a guideline and in no way replaces sound clinical judgment and professional practice standards. Inclusion Criteria: Children and adolescents 2-17 years of age being admitted with an acute exacerbation of asthma. Children admitted to PICU for treatment of severe asthma should be placed on the Inpatient Asthma Care Map when they are transferred to the ward at the discretion of the physician. Caution for children with co-morbid conditions such as cardiovascular disease, chronic lung disease, immunodeficiency syndromes. Inclusion of these children should be discussed with the physician. Exclusion Criteria: Children under 2 years of age Children with croup Children with active chicken pox Children in PICU Implementation Guidelines: 1. The Pediatric Asthma Inpatient Care Map Standard Orders (PHOR # 171) will reside in the Emergency Department CH4, and CH5 and PICU. 2. The Care Map will reside on CH4 and CH5, and will be initiated by ward staff on admission. 3. The admitting physician to complete the Pediatric Asthma Inpatient Care Map Physician s Order Sheet (PHOR #171) 4. Transcribe the orders onto the Care Map, Kardex, and Medication Administration Record (MAR) as appropriate. Discharge Outcomes: Clinical 1. Oxygen saturation on room air while awake > 91%. 2. Respiratory, neurological and cardiovascular status stable with salbutamol inhalation therapy at q3-4h intervals (as per physician's order). 3. If child > 5 years: Pulmonary Function Test pre and post bronchodilator therapy done or a referral to the Pulmonary Function Lab for post discharge follow-up has been done. Teaching 4. Discharge teaching has been completed. 5. Family receives and understands a written asthma discharge plan. 6. Family is able to afford discharge medications and/or provisions made as per social worker Follow up 7. Discharge prescriptions given if medications not available at home. 8. Referral to Children's Asthma Education Centre completed. 9. Family is aware to arrange follow-up appointment with primary care MD within 7 days of discharge. 10. Follow-up appointments as requested by the consulting sub-specialists (i.e. allergy, respirology) have been arranged if applicable. 11. Pediatric Asthma Discharge Plan (W-00080) (and Discharge Information Sheet only if applicable) has been faxed to the Primary Care Physician. FORM #NS00696 10/07 Pediatric Inpatient Asthma Care Map Page 1 of 8

DATE Date: Time of Admission: TIME Children's Hospital Nursing database completed on admission (Form # 85396). ASSESSMENTS Assessment q4h, (CNS, CVS and GI) as per nursing assessment parameters on page 6 of the Care Map... Respiratory Assessment and Asthma Clinical Score required (record on Pediatric Asthma Clinical Scoring Sheet):... - Pre/Post salbutamol inhalation therapy... - With worsening in clinical status... Orientation to unit and care... SAFETY / ACTIVITY Parent/Caregiver receives a copy of the Inpatient Pediatric Asthma Family Care Guide... Activity as tolerated... PSYCHO- SOCIAL Psychosocial assessment as per nursing assessment parameter on page 6 of the care map Consult to social work initiated within 24 hours of admission if it is identified that the family is unable to fill/refill a prescription due to financial constraints or if other social issues are identified during the admission.. TESTS/ CONSULTS Pulmonary Function Test (PFT) pre and post bronchodilator treatment done or arranged prior to discharge if child > 5 years... A referral is faxed to PFT lab... Referral to Children's Asthma Education Centre (CAEC).. Pulmonary Function Test pre and post bronchodilator treatment for a child 5 years if difficult to wean (i.e. > 4 masks at any one level when the inhalation frequency is q2h)... Vital Signs as per frequency table or with worsening in clinical status (recorded on the Pediatric Asthma Clinical Scoring Sheet). Supplemental oxygen to keep O 2 saturation > 91%... TREATMENT/ MEDICATIONS Oxygen is being weaned as per protocol... Oxygen saturation: - Pre/Post salbutamol inhalation therapy... - With worsening in clinical status. Medications are administered as per standard orders Frequency of Salbutamol is decreasing as per Weaning Protocol.. NUTRITION Pediatric Standard diet... Known food allergies considered... Parent/Caregiver has watched the Asthma video if child > 3 years Parent/Caregiver has received a copy of the Asthma Education Teaching Package TEACHING Family/Child demonstrates use of the following drug delivery techniques: How to Use the Puffer (Metered Dose Inhaler or MDI) (Form # W- 00075)... How to Use the Puffer (Metered Dose Inhaler or MDI) and Pediatric Spacer (Form # W-00077).. How to Use the Puffer (Metered Dose Inhaler or MDI) and Adult Spacer (Form # W-00077).. How to Use the Turbuhaler (Form # W-00076) How to Use the Diskus (Form # W-00076) Page 2 of 8 Pediatric Inpatient Asthma Care Map 10/07

DATE Date: TIME Discharge when the following criteria are met: Clinical 1. Oxygen saturation on room air while awake is > 91%... 2. Respiratory, neurological and cardiovascular status stable with salbutamol inhalation frequency at 3-4 hours (as per physician's order). 3. If child 5 years: Pulmonary Function Test pre and post bronchodilator therapy, or a referral to the Pulmonary Function Lab for post discharge follow-up has been done.. Teaching DISCHARGE PLANNING 4. Discharge teaching completed: a. Family is given a copy of Caring for Your Child s Asthma After a Hospital Stay (W-00014)... b. A review of the reasons to return to the hospital.. c. The role, dosing and scheduling of oral corticosteroids, relievers and controllers... 5. Family receives and understands a written Asthma Discharge Plan... 6. Family is able to afford discharge medications and/or provisions made as per social worker. Follow-up 7. Discharge prescriptions written for: a. Inhaled Beta Agonist Rx given Has at home... b. Inhaled Corticosteroid Rx given Has at home... c. Oral Corticosteroid Rx given Has at home... 8. Referral to Children's Asthma Education Centre completed... 9. Family is aware of need to arrange follow-up appointment with Primary Care MD within 7 days of discharge... 10. Follow-up appointments as requested by the consulting sub-specialists (i.e. allergy, respirology) have been arranged if applicable... 11. Pediatric Asthma Discharge Plan (W-00080) (and Discharge Information Sheet if applicable) has been faxed to the Primary Care Physician... Discharge Information: Discharge Date: Time: In the care of Parent/Guardian/Escort: Name: Relationship: Immediate Contact: Address: Phone: Caregiver agrees to follow-up contact for Quality Improvement purposes Yes No Signature Witness Signature: PLAN REVIEWED Plan Reviewed Initial... 10/07 Pediatric Inpatient Asthma Care Map Page 3 of 8

Extension Care Map DATE Date: TIME Assessment q4h, (CNS, CVS and GI) as per nursing assessment parameters on page 6 of the Care Map (chart assessment times in section below)... ASSESSMENTS Respiratory Assessment and Asthma Clinical Score required (record on Pediatric Asthma Clinical Scoring Sheet): - Pre/Post salbutamol inhalation therapy... - With worsening in clinical status... SAFETY / ACTIVITY Activity as tolerated... TESTS/ CONSULTS PSYCHO- SOCIAL Vital Signs as per frequency table or with worsening in clinical status (recorded on the Asthma Clinical Scoring Sheet)... Supplemental oxygen to keep O 2 saturation > 91%... Oxygen is being weaned as per protocol TREATMENT/ MEDICATIONS Frequency of Salbutamol is decreasing as per Weaning Protocol... Oxygen saturation: - Pre/Post salbutamol inhalation therapy... - With worsening in clinical status... Medications are administered as per standard orders. Pediatric Standard diet NUTRITION Known food allergies considered... TEACHING Psychosocial assessment as per nursing assessment parameter on page 6 of the care map.. Page 4 of 8 Pediatric Inpatient Asthma Care Map 10/07

Extension Care Map DATE Date: TIME Discharge when the following criteria are met: Clinical 1. Oxygen saturation on room air while awake is > 91% 2. Respiratory, neurological and cardiovascular status stable with salbutamol inhalation frequency at 3-4 hours (as per physician's order)... 3. If child 5 years: Pulmonary Function Test pre and post bronchodilator therapy, or a referral to the Pulmonary Function Lab for post discharge follow-up has been done... Teaching 4. Discharge teaching completed: a. Family is given a copy of Caring for Your Child s Asthma After a Hospital Stay (W-00014)... b. A review of the reasons to return to the hospital... c. The role, dosing and scheduling of oral corticosteroids, relievers and controllers. 5. Family receives and understands a written Asthma Discharge Plan 6. Family is able to afford discharge medications and/or provisions made as per social worker... Follow-up DISCHARGE PLANNING 7. Discharge prescriptions written for: a. Inhaled Beta Agonist Rx given Has at home... b. Inhaled Corticosteroid Rx given Has at home... c. Oral Corticosteroid Rx given Has at home... 8. Referral to Children's Asthma Education Centre completed... 9. Family is aware of need to arrange follow-up appointment with Primary Care MD within 7 days of discharge 10. Follow-up appointments as requested by the consulting sub-specialists (i.e. allergy, respirology) have been arranged if applicable 11. Pediatric Asthma Discharge Plan (W-00080) (and Discharge Information Sheet if applicable) has been faxed to the Primary Care Physician... Discharge Information: Discharge Date: Time: In the care of Parent/Guardian/Escort: Name: Relationship: Immediate Contact: Address: Phone: Caregiver agrees to follow-up contact for Quality Improvement purposes Yes No Signature Witness Signature: PLAN REVIEWED Plan Reviewed Initial. Extension Care Map Used YES (write a variance if used) 10/07 Pediatric Inpatient Asthma Care Map Page 5 of 8

Vital Sign Ranges (from PALS modified version 2005) Age Heart Rate (beats/min) Respiratory Rate (breaths/min) Preschool 80-140 22-34 School Age 70-120 18-30 Adolescent 60-100 12-16 Blood Systolic Pressure (mmhg) > 75 > 80 > 90 Vital Sign Frequency Parameter Admission Subsequent Assessments and Pre/Post Bronchodilator Treatments Temperature Q4h Heart Rate Pre/Post bronchodilator treatments Respiratory Rate Pre/Post bronchodilator treatments Blood Pressure Q4h with Q1h treatments Q12h BID when treatment frequency is > q1h Oxygen Saturation Pre/Post bronchodilator treatments Nursing Assessment Central Nervous Respiratory Cardiovascular Gastrointestinal Psychosocial Normal Parameter Alert, appropriate for age and/or developmental level. Behavior appropriate to situation. Good breath sounds (air entry adequate), no adventitious sounds or accessory muscle use. Respiratory rate as above. Oxygen saturation on room air > 91%. No pallor or cyanosis of nail beds or mucous membranes. Skin warm and dry. Mucous membranes moist Evidence of adequate hydration. No vomiting or diarrhea. Able to tolerate oral fluids. Good interaction noted between patient and caregiver. Caregiver shows appropriate amount of concern for the child and there is a reasonable level of understanding of the child's illness and treatment. No language barrier. Able to obtain medications. Page 6 of 8 Pediatric Inpatient Asthma Care Map 10/07

Helpful Hints for Using the Inpatient Asthma Care Map Nursing Database (#85396) needs completion upon admission; the Patient Activity Flow Sheet (#82137), the Vital Signs Record sheet (#82136), the Clinical Flow Sheet (#70060) ARE NOT required when using the Care Map. When a child comes to the ward at q1 hourly inhalation treatments, the resident/house staff will reassess the child following the third q hourly inhalation treatment. The child will be reassessed sooner if the nurse feels that the child s clinical status has deteriorated, or if there has been an improvement in the child s clinical status that would indicate that the child could be weaned to q90 minutes inhalation treatments or if at any time the nurse is concerned/uncomfortable with his/her clinical assessment. Weaning face mask treatments along the algorithm requires patient assessment by the house staff up until the patient reaches q2h frequency. Thereafter, the weaning can be done by the nurse only in accordance with the algorithm and clinical scoring tool. Orders for decreasing face mask frequency are not required on regular physician order sheets; documentation on the Integrated Progress Notes is sufficient. Remember that the method of inhalation treatment changes to an inhaler with AeroChamber at the q2h frequency. Special circumstances may present themselves to necessitate use of the face mask at this frequency. For example, when the patient is fatigued and it is the middle of the night. When using an inhaler and spacer device ensure the correct spacer is chosen for the child. The pediatric AeroChamber with mask (yellow) is intended for children 12 months to 5 years. The AeroChamber with mouthpiece (blue) is intended for children 5 years and older. The admitting nurse will document the admission date and time at the top of the Care Map. Nursing staff will indicate their type of shift (D8, D12, E1, E2, N8 or N12) in the appropriate columns and initial their care under the appropriate columns. Documentation using the Integrated Progress Notes by Nursing Staff is only done if further explanation is required to clarify an issue/problem. Do not double document on the Integrated Progress Notes if the information is clearly documented as a variance. If further explanation is required document see IPN in the appropriate column on the Care Map. Medical and Allied Health staff will continue to document in the IPN as their common practice dictates. 09/07 Pediatric Inpatient Asthma Care Map Page 7 of 8

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