A Caregiver’s

Perception of Control among Children

with Asthma

Latonda S. Paymon, MSN, FNP-BC, DNP

Troy University

Background of the Problem

¡  Sterling and Linville (2015) reported that in the United States more than seven million children are affected by asthma.

¡ In the United States, asthma affects 8.2% of the population (Yates, 2013).

¡ Asthma has also been linked to14 million school absences each year, and 80% to 90% of children encounter symptoms by the age of four (Conti, Bradwisch, & Donohue, 2014).

Background of the Problem

¡ Diminished lung function and recurrent symptoms predispose the asthma patient to a lifetime of limited activities and restricted quality of life (Wilson et al., 2015)

¡ Uncontrolled asthma accounts for 35% to 50% of medical cost in children (Yates, 2013)

¡ One out of every ten children attending school has asthma (Yates, 2013)

Purpose and Goals

¡ The purpose of the project was to examine the effects of Asthma Action Plans (AAPs) and use of peak flow meters on the caregiver’s perception of symptom control among children with asthma

¡ Implement AAPs and peak flow (PF) meters with caregivers and patients diagnosed with asthma for at least one year

¡ Improve caregiver’s perception of asthma control among children five to 11 diagnosed with asthma

Literature Review

Caregiver’s perception of control of the child’s asthma was selected as the outcome variable for the project

Databases included:

Cumulative Index of Nursing, OVID Nursing Journals, PubMed Central, and National Heart, Lung, and Blood Institute (NHLBI)

Key Words:

Asthma, clinical guidelines, asthma education, and caregiver’s perception

Literature Synthesis

¡  Recommendations-NHLBI and NAEPP (National Asthma Education and Prevention Program)

¡ Guidelines were employed to determine interventions needed when providing care to pediatric asthma patients

¡ Asthma therapy should concentrate on decreasing impairments and risks

¡  In order to maintain control, healthcare providers should administer appropriate medications, address environmental triggers, assist with self- management proficiencies, and monitor long- term control (AAPs)

¡ PF meters were recommended to aid in monitoring control

(Yates, 2013)

Middle Range Theory

§  Resiliency Model of Family Stress, Adjustment, and Adaptation (Resiliency Model) is a framework for families dealing with chronic health issues and addressed concepts of the caregiver’s load (Murdock, Adams, Pears, & Ellis, 2012)

¡ Model explained how stressors could effect caregivers as they learned to adapt to crisis (Shaw & Oneal, 2014)

¡ Adaptation Mechanisms are directly influenced by stressors and coping behaviors within a family (Murdock et al., 2012)

¡ Primary caregivers of a child with asthma manage additional responsibilities and if an unbalance occurs then negative outcomes may present (Murdock et al., 2012)

EBP Model

§ Stevens Star Model of Knowledge Transformation (Star Model) offered simple comprehensive methods of translating evidence into practice

§ Model used five points that included: discovery of research, evidence summary, translation of guidelines, practice integration, and outcome evaluations. The points transformed knowledge

§ Model served as a template for converting knowledge into information most beneficial to patients and caregivers

(Stevens, 2013)

Sample and Setting

30 caregivers of children five to 11 years old diagnosed with asthma for at least one year

Children were patients of the Federally Qualified Health Center (FQHC)

Caregiver and Child fluent in English

FQHC located in Alabama

Facility open Monday- Saturday from 8:00am until 4:30pm

Patients between ages of birth to 22

Two Nurse Practitioners and two Pediatricians

Project Objectives

¡  Investigate evidence on pediatric patients

¡  Secure approval from FQHC administrators

¡  Secure approval from Troy University IRB

¡  Recruit 30 caregivers of the sample population

¡  Collect Baseline and pre- intervention data

¡  Implement Peak Flow Meters and AAPs

¡  Collect post- intervention data

¡  Analyze data and Disseminate results

Data Collection Tools child Asthma Control Test (cACT)

Demographic Tool

Tool ¡ Assessed with Childhood Asthma Control Test (cACT)

¡ Self- administered tool

¡ Measures child’s and parent’s perception of control

¡ Overall score 0 to 27

¡ 0 poor control, 27 controlled

¡ Validated as a tool to assess control in childhood asthma

¡ Cronbach α of .79

¡ Excellent test-retest reliability tool

Pre- Intervention

¡ After obtaining approval from the facility and Troy University Institutional Review Board, 30 caregivers of children aged five to 11with asthma, diagnosed with asthma for a minimum of one year who were able to read, comprehend, and write English were recruited.

¡  Caregivers were contacted- if agreed to participate- scheduled for initial and 3- month follow appointment (routine visit schedule).

¡ At initial visit, informed consent completed by caregiver, code number assigned, assessment completed, and verbal assent read to child. Completed demographic tool, pre- intervention cACT, education session (peak flow education, AAPs, spacers, and asthma medication), pre-peak flow meter reading recorded and questions encouraged. The caregiver/ patient were given a peak flow meter, Rx for spacer was given, a copy of the AAP and a $10.00 Wal-Mart gift card.

Post-Intervention

¡ At follow-up appointment 3 months later, post-intervention assessment, demographic tool updated, cACT completed, and post peak flow meter reading recorded

¡  Post project survey was completed by the caregiver.

¡ $10.00 Wal-Mart card was given to the caregiver.

¡ Data was analyzed and disseminated.

Interventions ¡ Peak flow meter-

small hand-held device used to monitor how well the lung is functioning (L/min) ¡ Not covered by insurance

Guidelines Recommend Use of Spacer with Inhaled Medications

Data Collection Pre-intervention data

Demographic tool

cACT

Peak flow meter reading

Post-intervention data

cACT

Peak flow meter reading

Post project survey

Description of the Sample  

Table 1.

Mean, Standard Deviation and Range of Caregiver and Patient Age (N = 30)

Variable M SD Range

Caregiver’s age 33.37 6.07 24 - 48

Age of patient 7.67 1.68 5 - 11

Statistical Results Table 2.

Frequencies of Pre- and Post-Intervention Asthma Control and Hospital Visits (N = 29)

Pre-intervention Post intervention n % n %__

Asthma control

Poorly controlled 1 3.3 - -

Sometimes controlled 12 40.0 7 24.1

Usually well controlled 11 36.7 13 44.8

Well controlled 6 20.0 9 31.0

Hospital visits

Yes 5 17.2 1 3.4

No 24 82.8 28 96.6

Statistical Results: Frequencies

Characteristics of Post-Intervention Variables (N = 29) a

Characteristics n %

Symptom control

Very much 10 34.5

A lot 13 44.8

Some 5 17.2

Little/none 1 3.4

Asthma Action Plan Helpful

Yes 29 100

No 0 0

Peak Flow Meter Helpful

Yes 29 100

No 0 0

Statistical Results

Mean and Standard Deviation, and Range for peak flow and cACT total (N = 30)

Pre-Intervention Post –Intervention

M SD Range M SD Range

Peak Flow Meter (L/min) 218.17 52.03 150-390 214.83 53.76 100-36

cACT Total 18.60 4.90 8-25 18.69 5.62 6-26

Statistical Results: Chi-Square

Frequency and column percentages of asthma control (N =29) a

Pre-Intervention Post- Intervention_______________

Sometimes Usually Well Total

n % n % n % n %

Poorly 1 3.4 0 0 0 0.0 1 3.4

Sometimes 3 10.3 6 20.7 3 10.3 12 41.4

Usually 3 10.3 7 24.1 1 3.4 11 37.9

Well 0 0 0 0 5 17.2 5 17.2

Total 7 24.1 13 44.8 9 31.0 29 100_ _

Ҳ2(6) = 17.090, p < .0001

One-way-ANOVA of pre-and post-intervention PF meter reading and caregiver’s control

ANOVA of Peak Flow by Caregiver Perception of Asthma Control

Variable Groups Mean F p

Pre-Intervention

Peak Flow Poorly controlled 205.00 .433 .731

Sometimes controlled 231.67

Usually controlled 210.91

Well controlled 206.67

Post-Intervention

Peak Flow Sometimes controlled 162.86 5.834 .008

Usually controlled 229.23

Well controlled 234.44

Formative Evaluation

¡ Letter of approval was obtained from medical director at FQHC

¡ Troy IRB approval was granted after full review

¡ Collaborator and other providers supportive of initiation of AAPs and spirometry testing

¡ Collection of pre-and post-intervention data was achieved over 3 months

¡ 29/30 of the participants completed the project- one did not return for the follow-up appointment

Summative Evaluation

¡ Significant clinical improvement was achieved from pre- and post- intervention demonstrating the effectiveness of the AAPs and PF meters among asthma patients

¡ Utilization of AAPs and PF meters

Data revealed that participants thought AAPs and PF meters were helpful

After the initiation caregivers expressed an improve perception of asthma control

Implications for Practice Change &Sustainability

¡ AAPs and PF meters allow caregivers to have improved perception of control of the child’s asthma

¡ Project was partially sustained because providers at the FQHC initiated AAPs but PF meters were not implemented because of non- reimbursement by insurances. Spirometry equipment was purchased.

¡ Implementation of AAPs and PF meters enhance quality of care for both the caregivers and the patients

¡ Implementation of AAPs and PF meters improve reliability, consistency of care, and decrease costs associated with asthma

Recommendations for Nursing Practice

¡  The National Heart, Lung, and Blood Institute recommends that patients diagnosed with asthma receive an updated written AAP at each visit (Gillette et al., 2013).

¡  Research reports that only 21% of healthcare providers utilize AAPs (Gillette et al., 2013).

¡  Providers should take in account that caregivers are an important component of the disease management process, should step up and become an advocate for the asthma patient.

¡ Healthcare providers should implement evidence-based interventions that improve communications regarding asthma medications, triggers, signs and symptoms of exacerbations, and when and where to obtain urgent care.

¡ Advocate for coverage of peak flow meters by 3rd party payers.

Limitations

¡ Small sample size

¡ One clinic setting

Conclusion

¡ Asthma is a chronic lung disease that affects the entire family unit.

¡ The implementation of AAPs and PF meters are interventions that allow caregivers to have an increase in perception of control.

¡ Healthcare providers should continue to aim for interventions that enhance patient care and not evade outcome improving protocols.

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Asthma Control