Introduction

Introduction:
This assignment was brought to light in view of the Module ENP 5 in order for us as Pediatric nursing students to be able to reflect, in this case I will be reflecting on a case that happened during my practice where I had to rapidly assess and plan a teaching session directed at the patient and the caregivers, where coherence between assessment, teaching strategies and intended learning outcomes in an educational programme (McMahon & Thakore, 2006, p10) . The following events happened at where I am currently employed, SWFT NHS Warwick, Accident and Emergency department, November 2017, where a distressed caregivers and child attended to the department following symptoms of shortness of breath and was booked into triage by receptionist who flagged this child to the charge nurse where then the triage nurse did the initial assessment and a full set of observations, as the child allowed and asked them to accompany her to the pediatric waiting area. Following this the child was further assessed by the Dr’s who then established by asking the past medical history that the child suffered with asthma is a common, long-term disease. It affects about five million people in the UK, (British Lung Foundation, 2018) and that the symptoms were aggravated by this, Your airways carry air in and out of your lungs. If you have asthma, they are very sensitive. Certain things trigger the muscles around your airways to tighten, making your airways narrower. The airway lining also becomes inflamed causing a build-up of sputum. This makes your airways even narrower. With narrow airways, it’s harder to get air in and out of your lungs, (British Lung Foundation, 2018). Following this I will procced to analyse and critically reflect on my recollection of events and steps taken to ensure his family had the best care I could provide given my experience and scope of practice, all nurses must ascertain and respond to the physical, social and psychosocial needs of people, groups and communities. They must then plan, deliver and evaluate safe, competent, person centred care in partnership (Gopee, 2015).

Objectives:

When I assessed the need of these caregivers and child to have improved and correct the missing aspects of the Inhalation technique via spacer device and how will I achieve this as , to show an explanatory/didactic video that demonstrated technique (Observation and practical), as only 43% of children know how to use their inhalers correctly as (Gillette C, Rockich-Winston N, Kuhn JA, et al. Inhaler technique in children with asthma: A systematic review. Acad Pediatr. 2016 Apr 26).
Then to know if this has been achieved, asking the parents to simulate the technique shown to them and evaluated by observing if the technique was satisfactorily done, giving them time to ask any questions that my rise as they do so.

Analysis:
At the end of the teaching session the caregivers should be able to replicate and give the inhalation while using a spacer device correctly, as the importance of learning this technique correctly is key for the child as she will then be learning from good examples as she develops, according to bandura (1986), we do not possess any inherited behaviour patterns at birth except reflexes and therefore learning occurs by observing other people, which is the essence of social learning theory and which therefore includes from learning from social situations (Gopee, 2015) and will then be able to control her symptoms and ask the parents for the rescue inhaler as well as maintaining a daily routine of the prevention inhalers, as the caregivers in future will have to let the child take over her care as she transitions to adolescence.

With the therapies on it I then gathered the appropriate medication and equipment, given that the emergency has a high volume of patients I felt that I should make this contact count and give these parents and child tools and knowledge to use in future and prevent this from happening again to the best of their abilities, all members of the team, including the patient, family, and caregivers, need to be aware of these goals as an aspect of the patient’s total care. (Rcjournal.com, 2010)
The reason to why I engaged a with this family and asked them and child to show me the technique was because when I asked them if they knew how to use the inhaler they said they have used it before and the child had been taught how to do it but it was questionable how much of that information was retained and also how much of it would be retained after I had shown them how to correctly use it, as I knew the child would accept this being done by the family more than from me, …the care that children receive has powerful effects on their survival, growth and development…care refers to the behaviours and practices of caregivers (mothers, siblings, fathers and child care providers) to provide the food, health care, stimulation and emotional support necessary for children’s healthy survival, growth and development…Not only the practices themselves, but also the way they are performed – in terms of affection and responsiveness to the child – are critical to a child’s survival, growth and development (Apps.who.int, 2004), explained again as a step by step how to with special focus on the child who I also shown a cartoon video on how to use the inhaler and spacer which was a fun learning experience for the child as it has no negative influences on learning it, apart from the area being busy with other patients, staff and call bells ringing which I consider more of a negative for me as it requires more focus on my part, or to propose to our manager to provide us a quiet room with the purpose of providing any care or teaching required to patients and their caregivers, this to ensure a delivery of good quality care in teaching or treatment, given a different environment and time allowing I would have been able to explore more and go deeper into breaking down step by step while executing the technique with no distractions as follows on the following example shown on this table.
INHALER TECHNIQUE:
Adults, adolescents and children older than six years Pressurised metered dose inhaler (pMDI) with a spacer* or a dry powder inhaler (DPI) device. 1. Remove cap from the mouthpiece of the inhaler and shake well.2. If using the pMDI for the first time or when using after more than seven days, prime the
device by releasing one puff into the air.3. Attach inhaler to the back of the spacer and facemask.4. Hold upright, with thumb below the base and finger on top of the canister.5. Stand or sit upright and fully exhale through the mouth.6. Place the mouthpiece of the spacer between the teeth and seal the lips tightly around it. 7. As subject starts breathing in slowly through their mouth, press down once on the inhaler. 8. Keep breathing in as slowly and deeply as possible, holding the breath for at least 10
seconds or as long as possible (one-breath method). Alternatively, if unable to execute the
above, then inhale and exhale five times slowly through the spacer (standard method). 9. Wait about 15–30 seconds between puffs for short-acting ?2-agonist.
4–5 years pMDI with a valved spacer and mouthpiece. Repeat steps 1–7 as described above, then encourage the child to take 5–10 tidal breaths.
0–3 years pMDI with a valved spacer and face mask.A nebulizer with a face mask may be considered in children who are unable to use a spacer device effectively. 1. Remove cap from the mouthpiece of the inhaler and shake well.2. Attach inhaler to the back of the spacer.3. Place the face mask tightly over the child’s mouth and nose, ensuring a good seal. 4. Press down once on the inhaler.5. Allow and encourage the child to take 5–10 tidal breaths.6. Ensure that the valve is moving while the child is breathing.
(Asthma in the emergency department: Strategies beyond acute management protocols. research gate, 2018)
Having done this to the best of my abilities, given resources and space I had to do it in with all the background noise that I couldn’t control, I gave them as much time I could for them to demonstrate to me how to and explain to me why they were doing the steps on that order, to then discharging the patient who had greatly improved the symptoms that she presented with.
The parents and child were very receptive, cooperative and wiling to learn when taught and asked to replicate all the steps I was able to demonstrate, I feel that this experience is going to benefit my practice in a positive way, that will make me think in future that some of the reasons that bring parents to the department can sometimes be that they are not sure or lack of a skill and that I should make every contact count to the best of my abilities, as supported by the National Heart, Lung and Blood Institute (NHLBI) asthma guidelines recommend that providers confirm correct inhaler technique and impart asthma education at every interaction (Asthma in the emergency department: Strategies beyond acute management protocols. research gate, 2018) on an environment where all staff is constantly rushed, but being able to give good advice, for this we have on the department leaflets and/or refer to the appropriate healthcare professionals.

I have learned from this activity that questioning the parents and finding out how much they know already gives me a better view on what to focus on and aim to fill any gaps in knowledge that may need to be addressed although it would be ideal to have more time for this to happen, as time is of essence in a busy department, involving them in the treatment going through with them step by step to ensure good technique and correction where necessary to prevent further deterioration of the child, also giving the child chance to show if she is aware of how important this technique. Give the parents guidance as they to look for signs as for the child to be able to start to pre-empt when the usage of the inhaler and spacer to be used before any distress occurs.
Whenever you go to see your GP or asthma nurse about your asthma, whether it’s your annual asthma review, or another asthma appointment, ask them to check your inhaler technique. This is especially important if you’ve recently had symptoms or an asthma attack (asthma?, 2018).
What aggravates her asthma associated with any other activities and illnesses that may develop and the importance of having regular checks with the asthma nurse at her General practice to have a good record and control of her chronic illness.
This situation contributed to the child’s parents understand the technique of giving this medication in a more effective way, and gave the parents a new view on the illness and importance of recognizing early signs of deterioration and self-managing, in future I will question the parents and child if possible, adapting my approach to how much their collective knowledge is and how receptive they are to being assisted in filling the potential gaps in this knowledge.

This situation helped me developed and better understanding of breathing issues that could present in the department, mostly asthma as it can aggravate given any other respiratory illnesses. In annex I have elaborated a teaching session that I would have used provided I had more time to plan and deliver this.

Conclusion:
In conclusion, I found that the inhalation technique in children is normally very poor and needs more reinforcing and teaching strategies for children who have asthma and their caregivers although it is an essential technique to learn as it will be required throughout the patient’s life, tragically, three people die every day because of asthma attacks and research shows that two thirds of asthma deaths are preventable. The reassuring fact is that most people with asthma who get the right treatment – and take it correctly – can manage their symptoms and get on with what they want to do in life (asthma?, 2018), healthcare professionals should take time and instruct these children and caregivers on how to correctly Asthma UK has information about using your inhaler, and you can ask your nurse or GP for advice if you’re still not sure (nhs.uk, 2018), use these devices and give them time to practice and opportunity to correct any mistakes and doubts that may arise, given that sometimes the surrounding environment is sometimes not ideal to do so, we must them refer these children and caregivers to the appropriate channels so they can have more guidance, by having leaflets on the department and having videos that explain how to do these techniques correctly and how often to take your inhalers, use your preventer inhaler or tablets every day – this can help keep your symptoms under control and prevent asthma attacks (nhs.uk, 2018), these tools being age appropriate for children and adults as nowadays everyone has equal access to information online and can quickly refer to these, it makes it easier for the patients to adhere to these health habits and it is important to keep promoting these, either by integrating a day visit at schools for children with this particular need.

Teaching session:
Title: Correct Inhalation technique (via spacer device) (how will I achieve this?) and show explanatory/didactic video Demonstrate technique (Observation and practical), as only 43% of children know how to use their inhalers correctly as, (Gillette C, Rockich-Winston N, Kuhn JA, et al. Inhaler technique in children with asthma: A systematic review. Acad Pediatr. 2016 Apr 26). How to know if this has been achieved, by asking the parents to simulate the technique shown to them and evaluate by observing if the technique was satisfactorily done.

Aim of this: How to correctly use inhaler technique in young adults in accordance with the S.M.A.R.T. objectives relative to this teaching session.

Outcomes: At the end of the teaching session the parents should be able to replicate and give the inhalation while using a spacer device correctly.

Teacher activity: Explain and show technique (exemplify) at normal speed and then a breakdown of every step in less than 10 minutes.

Parents activity: Replicate the technique and give show knowledge of the key points of the technique with good effect to the child.

Resources needed: Inhaler and spacer device and child with respiratory distress and/or exacerbation of asthma.

References:
Academy, P. (2018). What are SMART objectives and how do I apply them?. online Professionalacademy.com. Available at: https://www.professionalacademy.com/blogs-and-advice/what-are-smart-objectives-and-how-do-i-apply-them Accessed 15 Oct. 2018.

Ucd.ie. (2010). online Available at: https://www.ucd.ie/t4cms/UCDTLT0022.pdf Accessed 15 Oct. 2018.

research gate. (2018). Asthma in the emergency department: Strategies beyond acute management protocols. online Available at: https://www.researchgate.net/publication/316552107_Asthma_in_the_emergency_department_Strategies_beyond_acute_management_protocols/citations Accessed 14 Oct. 2018.

asthma?, W. (2018). What is asthma? | Asthma UK. online Asthma UK. Available at: https://www.asthma.org.uk/advice/understanding-asthma/what-is-asthma/ Accessed 14 Oct. 2018.

Education for Health. (2018). Fun film encourages children to use inhalers – Education for Health. online Available at: https://www.educationforhealth.org/news/jack-blows-trumpet/ Accessed 15 Oct. 2018.

Gopee, N. (2015). Mentoring and supervision in healthcare. 3rd ed. SAGE, pp.22, 49.

Gillette C, Rockich-Winston N, Kuhn JA, et al. Inhaler technique in children with asthma: A systematic review. Acad Pediatr. 2016 Apr 26.

Summary by: Gregory Metz, MD, AE-C
Rcjournal.com. (2010). Providing Patient and Caregiver Training 2010. online Available at: http://www.rcjournal.com/contents/06.10/06.10.0765.pdf Accessed 16 Oct. 2018.

nhs.uk. (2018). Living with. online Available at: https://www.nhs.uk/conditions/asthma/living-with/ Accessed 14 Oct. 2018.

Surgenor, P. (2010). online Ucd.ie. Available at: https://www.ucd.ie/t4cms/UCDTLT0022.pdf Accessed 16 Oct. 2018.

Apps.who.int. (2004). The importance of caregiver-child interactions for the survival and healthy development of young children A REVIEW. online Available at: http://apps.who.int/iris/bitstream/handle/10665/42878/924159134X.pdf;jsessionid=2FEAC0A5A25FFB56754CADC8D5606708?sequence=1 Accessed 18 Oct. 2018.

British Lung Foundation. (2018). What is asthma?. online Available at: https://www.blf.org.uk/support-for-you/asthma/what-is-asthma Accessed 14 Oct. 2018.