Managing Asthma in Minnesota Schools

Schools play an important role in asthma management for children and adolescents. The goal of asthma management in school is for the student to be included in all educational activities, live as normal life as possible, and respond to asthma symptoms early to prevent complications from asthma. School nurses advocate for asthma-friendly policies and activities in the school environment and help to coordinate care for these students.

School health office

Not all Minnesota schools have a full-time licensed school nurse (LSN) on staff or in the health office.

MN Statute 121A.21 School Health Services requires:

(a) Every school board must provide services to promote the health of its pupils.

(b) The board of a district with 1,000 pupils or more in average daily membership in early childhood family education, preschool disabled, elementary, and secondary programs must comply with the requirements of this paragraph. It may use one or a combination of the following methods:

(1) employ personnel, including at least one full-time equivalent licensed school nurse;

(2) contract with a public or private health organization or another public agency for personnel during the regular school year, determined appropriate by the board, who are currently licensed under chapter 148 and who are certified public health nurses; or

(3) enter into another arrangement approved by the commissioner (of Education).

The health services staffing model and level of services varies among the public-school districts, charter and private schools. You can learn more about health services staffing models on the MDH School Health Services Staffing webpage.

It is important that parents ask who is providing health services in their student’s school. The actual person providing services could be a:

• Licensed school nurse
• Registered nurse
• Licensed practical nurse
• Unlicensed assistive personnel

While each of these health services staff support students with asthma, the role and type of support may vary based on nursing licensure or no licensure. MDH Nursing Practice in Schools webpage provides additional information. While each of these health services staff support student’s with asthma, the role and type of support may vary based on nursing licensure or no licensure.

Learn more

• Nursing Practice in Schools Provides information to guide nurses within the specialty practice of school nursing but also to help inform educators, administrators, and others who have limited knowledge about school nursing practices and the implications when practicing nursing in the school setting.
• School Health Services Staffing Provides additional information around staffing structures, types of nurses and staff supporting the School Health Services Team, and common questions about nursing practice in schools.

Working with students

• Any successful asthma care model should have the student as the center focal point.
• Every child who has asthma should receive appropriate age level asthma education with frequent assessment and management oversight by LSNs while at school
• Schools should work in partnership with students to plan, set goals and implement their asthma self-management plan.
• Supporting students by giving them the self-management tools they need to participate, also means identifying what their responsibilities are

For example, a student should:

• Complete and return all health-related paperwork, questionnaires, medication updates, etc., to health staff
• Follow district policies if they self-carry their medications and check-in with health staff at regular, predetermined intervals to evaluate their asthma status
• Report increasing (or decreasing) symptoms or changes in their asthma to health staff
• Report changes in peak flow readings to the health staff
• Understand how their AAP and/or medication care plan are used and when to request assistance
• Be responsible for carrying and using their asthma medications at the proper time (e.g., pre-medicating before sports activities), self-administering them correctly and not sharing medications with others
• Learn simple self-management tasks like awareness of their triggers, taking their medications as prescribed, and using their controller and quick-relief inhalers when needed.

Learn more

• MDH Asthma Action Plans - AAP templates that can be completed by your health care provider
• MDH School Resources - School policies and templates (health office and environmental), educational and information resources, tools and forms for the school health office
• American Lung Association – Improve Asthma Management in Schools Asthma materials for schools include school and community policy suggestions, assessment tools, action steps and learning modules for school personnel, the student and family
• How Asthma-Friendly is your school? (PDF) National Heart, Lung & Blood Institute – Students who have asthma need proper support at school to keep their asthma under control and be fully active
• Tools to Address Vaping in Schools - The state of Minnesota requires public schools to implement e-cigarette and vaping prevention curriculum for grades 6-8. For high school students, e-cigarette and vaping prevention curriculum is encouraged but not required.

Working with families

A child’s asthma can affect the dynamics of the entire family, so it’s important to understand what a family experiences when dealing with a chronic health condition like asthma. Families may not fully understand asthma and how to manage it properly. School health staff can help families by providing educational resources and materials about asthma and organizing training workshops for the school and community or by providing asthma education for the individual student and their family. Individualized education sessions could be offered during teacher conference days or during other school events.

Health staff have the opportunity to educate families regarding asthma triggers in the home and can help them create a healthy home environment. Since children who have asthma are extremely sensitive to their environment, an environmental assessment should be done in both the home and school environments. An assessment can help identify asthma triggers and identify solutions that minimize exposure to those triggers. Some local public health agencies offer asthma home based services that include a home environmental assessment and individualized asthma self-management education in the child’s home.

See Asthma Home Based Services section for more information or consult with your health care provider for resources available in your area.

Communicating with the student’s family and health care provider require tools that create an opportunity for collaboration - among school staff, like teachers, the parent or guardian and the health care provider.

• A written asthma action plan (AAP) is a tool developed by the health care provider in collaboration with the student’s parent/guardian. Health staff can encourage parents/guardians to participate in the asthma management process by asking their child’s provider to develop and share an individualized AAP (also called an asthma management plan) with the school; to write prescriptions for medication supplies that remain in the school health office; and by returning all required paperwork the school requires to help their child successfully manage their asthma.
• Parents/guardians should be notified when a student’s asthma symptoms are flaring up or when health staff have any related concerns such as when asthma related medication supplies are running low.
• Establishing an open, two-way line of communication with families promotes consistent and current information and can lead to successful asthma management for the child who has asthma.

Working with health care providers

The triangle of teamwork and communication among the school, health care provider and parent/guardian, is crucial to successful asthma management. School health staff should consider this an integral part of their role. Many times school health staff may be the first to recognize symptoms that are consistent with asthma.

Evaluation and proper follow-up with referral to a health care provider opens the door toward establishing a collaborative relationship between school health staff, the health care provider and the parent/guardian. School health staff should obtain parental/guardian permission (release of information consents) prior to contacting and communicating with a student’s health care provider directly. This step in the communication process is important as staff work to build communication pathways with providers, clinic care coordinators and other health professionals who may be working with a student who has asthma.

The LSN/RN is the person responsible for establishing this network and other health staff can support this relationship by providing the LSN/RN with clear and concise observations. Information that is provided in writing is much easier to respond to and less likely to be misinterpreted. For consistency and accuracy, school health staff should use district-approved forms when documenting information or entering data into the district's electronic health record.

The health care provider can communicate with the school health office by:

• Providing written, complete and up-to-date Asthma Action Plans (AAPs). Note that schools/districts typically require a new or updated AAP every school year.
• Performing student self-carry assessments and documenting permission for
• that student to self-administer and carry their asthma inhaler.
• Communicating special student needs: i.e., if a student requires further education or support when taking medication or checking peak flow readings, or by clarifying specialized care plan instructions.
• Writing prescriptions so a student has proper medications while at school: i.e., a rescue inhaler and holding chamber/spacer should be available at school and at home.
• Promptly completing and returning assessments and paperwork provided by school health staff that comply with district policy and guidelines.
• Contacting and discussing the child’s asthma management plan with appropriate school health staff.
• Obtaining parent/guardian signatures on consent to release/share information forms between the clinic and school when the parent is present at the clinic with the student and ensuring that paperwork is returned to the school health office.

School health staff responsibilities when providing information to health care providers vary greatly depending on school district policy and guidelines, as well as professional licensure.

Healthy children learn better

Poorly controlled asthma can affect a child’s ability to learn. It can disrupt sleep, the ability to concentrate, memorize, and, when not managed properly can prevent a student from participating in “normal” school activities. Children who miss school due to uncontrolled asthma not only miss classroom instruction, they also miss out on social interactions with other children, which can lead to fears of social isolation, rejection, and believing they are “different” from other children.

Effective asthma management can result in:

• A supportive learning environment for students who have asthma.
• Reduced absences. Students having fewer episodes and symptoms are treated earlier.
• Reduced disruption in the classroom. Students have fewer symptoms when they and their caregivers follow their asthma action plan.
• Appropriate emergency care. School staff members are prepared to respond to emergencies.
• Students fully participating in physical activities. Physical education (PE) instructors and coaches know how to prevent exercise induced asthma (EIA).
• Increased classroom time. Students spend less time in the nurse’s office and away from class when asthma is well managed and under control.

Asthma action (management) plans

The Asthma Action Plan (AAP) is a personalized, written tool that help students and staff manage an individual student’s asthma. All students who have asthma should have a personalized AAP; especially students with persistent asthma (mild, moderate or severe). Some AAP’s include embedded consents within the body of the plan that promote the sharing of information (and consent to administer medication at school) between the school and health care provider. Be sure to consult your school district policy and guidelines about using an AAP with these specialized consents.

AAP’s come in a number of formats. The most common includes the green-yellow-red zone format and may be symptom or peak flow driven. Each zone has assessment measures and tailored instructions specific to that zone. Some students can benefit from using both symptoms and peak flow measurements to determine their current asthma zone. Use whichever indicator is more significant for that student.

For example, if a student is coughing, but blows a green zone peak flow reading (above 80% of that student's personal best peak flow rate), that student may still be in the yellow zone, due to the presence of asthma symptoms. Once it’s determined what zone a student is in, follow that zone's directions in administering medications and when to seek medical care.

• Green =GO (feeling good, no symptoms, peak flow between 80-100%). Children whose asthma is well controlled should be in this zone all of the time. By following the instructions in the green zone, students can often avoid slipping into the yellow or red zones. This zone also includes instructions for the control medications the child may take every day (if they require a daily controller medication), and it includes medication instructions for students who develop exercise-induced symptoms due to strenuous activity.
• Yellow = CAUTION (having some asthma symptoms, peak flow is 50-80%). A student may slip down into this zone if they forget to take their control medication (if prescribed) or if they’re exposed to asthma triggers. This zone provides specific instructions for rescue or quick-relief medication administration when the student is starting to have asthma symptoms. If action is taken while the student's asthma is in the yellow zone, the student may avoid dropping into the more dangerous red zone.
• Red = DANGER (severe symptoms, peak flow less than 50%). A student with asthma symptoms or peak flow in this zone is an emergency. He/she needs immediate medical attention. Follow the instructions regarding emergency treatment and medication administration. If the student is struggling to breathe, give red zone medication and call 911, if there is no significant relief.