Green, yellow, and red zones aid troubleshooting
Ten years ago, nurse practitioners collaborated with pediatric pulmonary allergists at St. Louis Children’s Hospital to develop a plan to manage asthma cases within the hospital setting.
The plan was necessary because there was not much continuity of care and asthma was, and continues to be, the No. 1 reason for hospital admissions. About 1,000 children per year are admitted to St. Louis Children’s Hospital for asthma, says Anne Borgmeyer, MSN, RN, CPNP, AE-C, a nurse practitioner with the asthma intervention model.
An intervention model was developed and used successfully by the nurse practitioners. And an asthma pathway that was based on the intervention model was created to guide the care of all children admitted with asthma. Also, an asthma action plan was produced, which is the key education piece for families. Health care providers, school nurses and answer line nurses, and nurses who answer calls for community providers after hours all use the same action plan. Both the pathway and plan are patterned after national guidelines.
The asthma action plan is based upon the stoplight system, with a green, yellow, and red zone. When children are in the green zone, their asthma is in control. Those in the yellow zone are experiencing early signs of asthma. The red zone is the emergency zone when the child must contact their physician and seek medical care. (See Asthma Action Plan.)
The most important piece of the action plan is the green zone, which provides guidelines for families on how to help a child stay well.
To help a child stay well, he or she is placed on proper medication according to national guidelines. Children who have asthma symptoms two times a week or nighttime coughing, or symptoms more than twice a month should be on a controller medicine, says Borgmeyer. "Children with persistent asthma should be on a controller every day in that green zone, and a lot of times it is overlooked," she explains.
In addition, older children are given a peak flow meter, which is a tool that is used to monitor their asthma. To determine their best peak flow reading, children blow into the peak flow meter when they are well for a period of two to three weeks. Guidelines are followed to determine the best peak flow number based on a child’s height.
Peak flow helps identify zones
Children with moderate to severe asthma are encouraged to determine their peak flow on a daily basis. Those with intermittent or mild asthma are told to monitor their peak flow when they are beginning to feel symptoms. This way, the older children, ages 7 and older, can determine if they are in the green zone or yellow zone.
A peak flow reading in the green zone is 80% to 100% of the child’s best, and a peak flow reading that would place a child in the yellow zone is 50% to 80% of his or her best.
Children in the green (well) zone have no signs of asthma, are able to do normal activities, and have no problems while sleeping. When a child begins to experience signs of asthma such as coughing, wheezing, tightness of chest, shortness of breath, cold symptoms, and the inability to do normal activities or sleep at night, he or she is in the yellow (caution) zone.
Parents of young children who cannot monitor their peak flow must be very aware of the child’s symptoms so they can take steps to prevent the child from going into the red (danger) zone, says Borgmeyer.
When children are in the yellow zone, they are told to take two to four puffs of albuterol (an oral steroid) one to three times in the first hour and check their peak flow. If signs of asthma return, they are to continue to take albuterol every four hours as needed.
Those who are not back in the green zone after the first hour need albuterol more often than every four hours, or need it every four hours for more than one day, are told to call their doctor or nurse practitioner. "The whole idea is to get them in contact with their health care provider quicker so they can be managed before they get into that serious emergency zone," says Borgmeyer.
Parents often mistake asthma for cold
Often, parents miss the first signs of asthma because they think the child has a cold. However, with the asthma action plan, they are advised to go directly to the steps in the yellow zone when the child does not feel well. Parents are told, if their child is not feeling right, to think asthma first rather than last, says Borgmeyer.
When a child’s peak flow is below 50% of his or her best, and there are signs of advanced asthma such as difficulty breathing, trouble talking or walking, and constant coughing, the action plan indicates that emergency help is required.
Children are advised to take albuterol and contact their physician or nurse. Often when the steps are followed for the red zone in the action plan, children who go to the emergency department do not have to be admitted to the hospital, says Borgmeyer.
The asthma action plan is effective because families learn how to use it. Also, other key people in a child’s life follow the plan.
Annually, St. Louis Children’s Hospital sends an updated action plan to community providers within a 50-mile radius of the health care facility. School nurses also receive an action plan and education about its use. Through the Healthy Kids Express program, a van of health care professionals travel to schools and work with school nurses to provide asthma care to the children. The hospital also works with the Asthma and Allergy Foundation in St. Louis to help educate day care providers about asthma.
The multidisciplinary Asthma Education Committee at St. Louis Children’s Hospital keeps abreast of changes in practice and also develops resources for education. For example, they have written easy to follow instructions on medications and other asthma tools with the permission of the manufacturers. This way, baby-sitters or relatives have easy-to-follow instructional materials. They have also created a 20-page educational booklet for families.
When families leave the hospital with an action plan, they have a guide for self-management — not only for the routine days, but also for the times that symptoms indicate the child is in the yellow or red zone and needs to take quick relief measures.
Source
For more information about the asthma action plan, contact:
- Anne Borgmeyer, MSN, RN, CPNP, AE-C, Nurse Practitioner, Asthma Intervention Model, St. Louis Children’s Hospital, One Children’s Place, St. Louis, MO 63110. E-mail: [email protected].
Ten years ago, nurse practitioners collaborated with pediatric pulmonary allergists at St. Louis Childrens Hospital to develop a plan to manage asthma cases within the hospital setting.
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