"Applied Science, Faculty of"@en . "Nursing, School of"@en . "DSpace"@en . "UBCV"@en . "Harris, Jodi"@en . "2017-04-12T15:59:51Z"@* . "2017-04"@en . "Asthma is one of the most common illnesses in childhood. The development of asthma occurs early in life and is associated with many risk factors. However, identification and diagnosis of asthma in children is challenging. This is due to variability of disease presentations, as well as the inability of some children to perform diagnostic tests essential for accurate diagnosis. Therefore, it has been recommended a tool be created to assist in the diagnosis of asthma in children less than 6 years old. Given this salient recommendation, the purpose of this project is to develop a symptom mapping tool (in the form of a diary) Nurse Practitioners can offer to parents of children under 6 years old with suspected asthma, who have not yet been diagnosed. This diary will act as a travelling chart that serves to document episodes mirroring the development of asthma. In order to create this tool, a comprehensive literature review was completed and as a result, \u00E2\u0080\u0098My Breathing Buddy\u00E2\u0080\u0099 was created. This tool helps parents provide pertinent diagnostic information regarding symptoms related to upper respiratory illnesses that mimic asthma. Ultimately, this tool aims to empower parents and integrates both the patient and parent into the diagnostic process."@en . "https://circle.library.ubc.ca/rest/handle/2429/61196?expand=metadata"@en . "Running head: NURSING 596 CULMINATING PROJECT 1 A DIARY FOR PARENTS OF CHILDREN WITH SUSPECTED ASTHMA by JODI HARRIS BScN, Kwantlen Polytechnic University, 2012 A CULMINATING PROJECT SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF NURSING \u00E2\u0080\u0093 NURSE PRACTITIONER in THE FACULTY OF GRADUATE AND POSTDOCTORAL STUDIES (School of Nursing) THE UNIVERSITY OF BRITISH COLUMBIA Vancouver April/2017 \u00C2\u00A9 Jodi Harris, 2017 NURSING 596 CULMINATING PROJECT 2 Abstract Asthma is one of the most common illnesses in childhood. The development of asthma occurs early in life and is associated with many risk factors. However, identification and diagnosis of asthma in children is challenging. This is due to variability of disease presentations, as well as the inability of some children to perform diagnostic tests essential for accurate diagnosis. Therefore, it has been recommended a tool be created to assist in the diagnosis of asthma in children less than 6 years old. Given this salient recommendation, the purpose of this project is to develop a symptom mapping tool (in the form of a diary) Nurse Practitioners can offer to parents of children under 6 years old with suspected asthma, who have not yet been diagnosed. This diary will act as a travelling chart that serves to document episodes mirroring the development of asthma. In order to create this tool, a comprehensive literature review was completed and as a result, My Breathing Buddy was created. This tool helps parents provide pertinent diagnostic information regarding symptoms related to upper respiratory illnesses that mimic asthma. Ultimately, this tool aims to empower parents and integrates both the patient and parent into the diagnostic process. Keywords: Asthma; Diagnosis; Child; Children, Preschool; Pediatrics, Respiratory Tract Diseases; Chronic Disease; Health Promotion NURSING 596 CULMINATING PROJECT 3 Table of Contents Methods\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6... 6 Asthma as a Disease\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6 7 Risk Factors for Asthma\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6..8 Symptoms and Triggers\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6.. 9 Diagnosis\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6... 11 Parental Understanding and Health Literacy\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6 13 Review of Clinical Indices\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6 16 API Analysis\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6. 17 PIAMA Analysis\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6... 18 Asthma Diaries\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6.. 20 Appropriateness of Diaries for Asthma \u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6... 22 Design of My Breathing Buddy.\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6...\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6 23 Limitations to Diary Use\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6... 24 Implications for Practice\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6... 26 Creation of My Breathing Buddy\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6...\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6...28 Conclusion\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6 31 References\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6..32 Appendix A\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6..\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6..39 Appendix B\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A640 NURSING 596 CULMINATING PROJECT 4 Nursing 596 Culminating Project Literature Review: A Diary for Parents of Children with Suspected Asthma Asthma is one of the most common chronic childhood illnesses (Gina, 2015; Looijmans-van den Akker, Luijn & Verheij, 2016; Spahn & Covar, 2008). It is a disease characterized by reversible airflow obstruction, bronchial hyper-reactivity, and inflammation (Brashers, 2010). Asthma often results from the complex interaction between a host\u00E2\u0080\u0099s genetics and their environment (Szefler et al, 2014). Exposure to antigens found in the environment creates a cascading immune response within the lung tissue that leads to alterations in the inflammatory pathways, resulting in an initial presentation of chest constriction, expiratory wheezing, dyspnea, nonproductive coughing, prolonged expiration, tachycardia, and tachypnea (Brashers, 2010; Spahn & Covar, 2008; Szefler et al., 2014). The age of onset of asthma is variable, but generally occurs early in life and is associated with many known risk factors; early identification in childhood may help prevent the development of future lung abnormalities (such as the remodeling of airways) in adulthood (Brashers, 2010; Huffaker & Phipatanakul, 2014; Spahn & Covar, 2014). Asthma is a disease process that changes throughout life with a peak prevalence during childhood, with some children outgrowing the disease while others experience subsequent relapses and remissions, all often occurring before 6 years of age (Bisgaard & B\u00C3\u00B8nnelykke, 2010; Ducharme, et al., 2015; Looijmans-van den Akker et al., 2016). Its prevalence in Canada has been increasing over the past ten years while the incidence of asthma attacks remains stable (Statistics Canada, 2016). Practitioners should base diagnosis on a compatible history, which includes recurrent episodes of wheezing, cough, difficulty breathing, and chest tightness, as well as a physical exam (BC Guidelines, 2015). However, diagnosis in children who are less than 6 years of age is difficult due to the absence of ability to complete diagnostic tests such as NURSING 596 CULMINATING PROJECT 5 pulmonary function tests and peak expiratory flow tests, both of which are essential for the correct diagnosis of asthma (BC Guidelines, 2015; Looijmans-van den Akker, et al. 2016; Panettieri et al., 2008). Researchers suggest a diagnosis of asthma in children requires objective documentation of signs and symptoms or convincing parent reported symptoms of airflow obstruction (Ducharme, et al., 2015). However, many children present to health care professionals with an absence of traditional symptoms characteristic of asthma (such as wheezing), resulting in providers relying heavily upon parental reports of symptomatic responses to trial medications and past treatments (Ducharme, et al., 2015). More importantly, children with undiagnosed asthma utilize healthcare services more frequently than children with appropriately diagnosed and managed asthma (Szefler et al., 2014). Therefore, knowledge pertaining to other factors such as emergency department use, hospitalizations, and unscheduled clinic visits are instrumental for the assessment and diagnosis of asthma in the pediatric population (Szefler et al., 2014). This diagnostic challenge has resulted in many practitioners becoming reluctant to diagnose asthma in children under 6 years of age, and instead resort to utilizing alternative diagnoses such as \u00E2\u0080\u0098viral induced wheeze,\u00E2\u0080\u0099 \u00E2\u0080\u0098bronchospasm,\u00E2\u0080\u0099 or \u00E2\u0080\u0098reactive airway disease\u00E2\u0080\u0099 (Ducharme et al., 2015), thus contributing to suboptimal management. Practitioners cannot effectively predict or prevent disease, and the current treatment of asthma and other respiratory disorders in children is viewed as inadequate and cumbersome (particularly if early in life), resulting in disease fatigue on the part of both the parent and child (Bisgaard & B\u00C3\u00B8nnelykke, 2010; Link, 2014). Disease fatigue is described as the persistent overwhelming condition that parents experience when caring for children with chronic illnesses (Melnyk, Forehand, Moldenhouer & Small, 2001). The reality of many chronic illnesses is they are fraught with NURSING 596 CULMINATING PROJECT 6 exacerbation and deteriorations in the children\u00E2\u0080\u0099s quality of life and functioning (Melnyk et al., 2001). Thus creating a state of being characterized by anxiety, fear and disruption related to the spontaneous and often unexpected nature of chronic diseases such as asthma (Melnyk et al., 2001). The Canadian Pediatric Society has recommended the development of a tool or resource which will assist in accurate parental reporting and documentation of symptoms related to asthma (Ducharme et al., 2015). Given this recommendation, the purpose of this manuscript is to assist in the development of a symptom mapping tool (in the form of a diary) that Nurse Practitioners can offer to parents of children under 6 years of age with suspected undiagnosed asthma. In order to create this tool, support from a comprehensive literature review is necessary. This review highlights asthma as a disease, symptomology, how it is diagnosed, treated and how parental perceptions of asthma can impact outcomes. It then goes on to critically analyze various predictive indices currently in use in primary care settings. Next, the review identifies existing diaries and discusses both the merits and downfalls of each; and finally, implications for nurse practitioner practice will be discussed. Methods A comprehensive search was performed on various databases within the University of British Columbia online library. Utilized databases included Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medline, Pubmed, and PsycINFO. The search was limited to English-language articles published between 2000 and 2016. The search was also restricted to include scholarly peer reviewed articles from academic journals. Additional inclusion criteria included qualitative, quantitative, cohort or systematic reviews (including retrospective analyses and nested studies). Chosen articles were those focused on examining pediatric patients with NURSING 596 CULMINATING PROJECT 7 asthma and the clinical process that accompanied the diagnosis. Exclusion criteria included literature reviews, case studies, opinion pieces, editorials, Master\u00E2\u0080\u0099s thesis documents, and dissertations. The search was conducted using the following Boolean operators independently and in combination in an effort to obtain articles which met the inclusion criteria: asthma, asthma diary, asthma diagnosis, asthma in children, asthma management, and parental asthma. The combinations of asthma AND diary yielded 1,142 results in CINAHL and Medline. PsycINFO yielded 21 results when asthma diary was searched. Pubmed yielded a result list of 102 when the keywords \u00E2\u0080\u009Casthma diaries in pediatrics\u00E2\u0080\u009D were utilized. Titles of relevant articles were scanned for relevance. Potential literature was then eliminated if key components were not stated, for example if asthma or pediatric population was not the focus of the article. For example, in the Pubmed result list of 102 publications, articles were excluded based on title, focus, date and study conduction method, resulting in two articles selected for further review. Remaining articles were then assessed by reviewing abstracts and discussions. When reviewing abstracts, particular attention was paid to the purpose, results and outcomes. Discussion sections were reviewed in detail. Altogether, 35 articles originating from the CINAHL, Pubmed, PsychINFO, and Medline were included. Asthma as a disease Asthma is multifactorial, heterogeneous disease characterized by airflow obstruction resulting from the cumulative effects of smooth muscle constriction around airways, airway wall edema, intraluminal mucus accumulation, inflammatory cell infiltration of the submucosa, and basement membrane thickening (GINA, 2015; Sawicki & Haver, 2016). All asthmatic patients have airway inflammation with subsequent altered airway function and symptoms (Panettieri et NURSING 596 CULMINATING PROJECT 8 al., 2008). Furthermore, most (if not all) patients have some form of airway remodeling which worsens over time; however, this is largely evident by 6 years of age (Panettieri et al., 2008). Studies suggest the airway remodeling that occurs in asthma can be present in young children with the disease and appears to be acquired soon after the onset of disease symptoms (Saglani et al., 2007; Spahn & Covar, 2008; Szefler et al., 2014). These airway changes are responsible for the clinical manifestations of cough, wheeze, shortness of breath and chest tightness. Clinically, initial asthmatic response begins immediately after exposure and lasts for up to 2 hours (Brashers, 2010). Allergens bind to mast cells within lung tissue which directly triggers an immune response involving airway smooth muscle constriction (bronchospasm), increased vascular permeability (mucosal edema), and an increase in mucus secretion (Brasher, 2010). Eventually, the late asthmatic response occurs 4 to 8 hours later and can last up to 24 hours post allergen exposure (Brashers, 2010). The immune factors involved in asthma attacks (primarily IgE) contribute either directly to airway inflammation and irritation, or indirectly through the modulation of lung-specific or systemic immune responses (Link, 2014). Risk Factors for Asthma A number of risk factors are cited as contributing to the development of the disease, including variances in genetic phenotypes, presence of atopy or eczema, socioeconomic factors, daycare attendance, viral illnesses, sensitization to allergenic foods such as egg whites and nuts, gastroesophageal reflux, and environmental and in utero exposure to toxins - for example air pollution or tobacco smoke exposure (Amin et al., 2014; Bisgaard & B\u00C3\u00B8nnelykke, 2010; Brashers, 2010; GINA, 2015; Klinner et al., 2001; Link, 2014; Spahn & Covar, 2008). Moreover, older age at first wheezing episode, asthma in one or both parents, eosinophilia, wheezing without colds, and allergic rhinitis are also mentioned in literature as being risk factors NURSING 596 CULMINATING PROJECT 9 (Amin et al., 2014). Klinner et al. (2001) states parental asthma as a risk factor is not limited to the presence of maternal asthma, but those children whose father also had asthma were more likely to have asthma at school age. However, atopy appears to be the strongest and most consistently observed risk factor for the development of asthma (Amin et al, 2014). The association between atopy and the development of asthma derives from the notion of extreme cleanliness in western cultures called the \u00E2\u0080\u009Chygiene hypothesis,\u00E2\u0080\u009D in which lack of early exposure to various airway irritants in very clean households (such as pet dander and dust) favors already sensitized phenotypes and permits induction of asthma (Amin et al., 2014; Brashers, 2010, p. 1331). In fact, primary prevention of asthma through allergen avoidance is generally not recommended in international guidelines as it has a counterintuitive effect (GINA, 2015; Link, 2014; Panettieri et al., 2008). Symptoms and Triggers Wheezing in conjunction with viral infections is the most common presentation of asthma in early life (Link, 2014; Singh, Moore, Gern et al., 2007; Szefler et al., 2014). Suspicion for a diagnosis of asthma in the preschooler include parental report of the child having at least 1 of the following: a tight or clogged chest or throat, difficulty breathing or wheezing which occurs during or after exercise, prolonged exhalation, or wheezing or whistling in the chest in the previous 12 months (Amin et al., 2014; Link, 2014). It is very common for children to experience one or more wheezing episodes before the age of 3 years (Singh et al., 2007). Moreover, there is an inherent difficulty in making the diagnosis of asthma as there is a multitude of other common conditions that can mimic the disease, with presentation patterns often being concurrent (Spahn & Covar, 2008; Szefler et al., 2014). Some studies suggest a link between early respiratory infections and the development of asthma, however, only a minority of NURSING 596 CULMINATING PROJECT 10 children who experienced wheezing with viral respiratory tract infections during the first 3 years of life went on to develop asthma later in childhood (Bisgaard & B\u00C3\u00B8nnelykke, 2010; Link, 2014). Additional studies show less than 50% of children with early-onset wheezing will go on to develop asthma (Bisgaard & B\u00C3\u00B8nnelykke, 2010). Symptoms occurring in the first 3 years of life are often transient, and at school age, 75% of diagnosed asthmatic patients will outgrow asthma by mid-adulthood (Bisgaard & B\u00C3\u00B8nnelykke, 2010). The typical wheezing pattern in healthy infants and preschool aged children consists of short but recurrent exacerbations of cough and wheeze triggered by viral infections but characterized by periods of long, symptom-free intervals (Link, 2014). Studies suggest dividing children into two categories: transient and persistent \u00E2\u0080\u009Cwheezers.\u00E2\u0080\u009D Persistent wheezers were more likely than other children to have mothers with asthma, increased serum IgE levels both in their first year and at age 6 years, and normal lung function in their first year but diminished function at age 6 years (Panettieri et al, 2016). By contrast, the transient wheezers were more likely to have mothers who smoked but not mothers with asthma (Panettieri et al, 2016). Transient wheezers had diminished airway function both before age 1 year and at age 6 years and did not have increased serum IgE levels or skin test reactivity (Panettieri et al, 2016). For those who had wheezed before age 3 years (both persistent and transient early wheezers), poor lung function (assessed by specific airway resistance) at age 3 years predicted the persistence of wheezing at age 5 years (Panettieri et al, 2016). Triggers for asthma are numerous and include tobacco and wood smoke, dust mites, animal dander, cockroach allergens, and indoor mold, with tobacco exposure being cited as the strongest known environmental modifier of the natural history of the disease (Bisgaard & B\u00C3\u00B8nnelykke, 2010; Chui, 2015). Exercise, changes in weather, and emotions can also exacerbate NURSING 596 CULMINATING PROJECT 11 symptoms of the disease (Chui, 2015). Medication use can be a trigger for the development of asthma such as aspirin or beta adrenergic blocking agents, although this is very rare (Chui, 2015; Link, 2014). Furthermore, despite the association of allergies and asthma, researchers suggest perennial and multiple allergies are rare in the first years of life, and this mechanism can only explain a minority of cases of asthma in the population and an even smaller proportion of preschool wheezers (Bisgaard & B\u00C3\u00B8nnelykke, 2010). Therefore, triggers are often individual and variant and thus difficult to pinpoint. Diagnosis Asthma is a syndrome with little consensus and classification of symptoms, which is subject to large variations among patients, physicians, changes in diagnostic traditions over time, as well as with a variable clinical course (Bisgaard & B\u00C3\u00B8nnelykke, 2010). Furthermore, it is difficult to accurately diagnose asthma in children when they experience their first episodes of wheezing as evaluation and treatment algorithms are complex (Bisgaard & B\u00C3\u00B8nnelykke, 2010; Link, 2014). In fact, many physicians are more likely to use the term asthma if a child is known to be allergic, capturing a particular phenotype while potentially excluding others (Bisgaard & B\u00C3\u00B8nnelykke, 2010). Asthma diagnosis should instead be based on reported respiratory symptom patterns and evidence of airway bronchodilator reversibility or airway hyper-responsiveness in response to specific triggers (GINA, 2015; Szefler et al., 2014). Traditionally, asthma diagnosis includes spirometry and peak flow measurements, both of which are considered gold standards. There are three key elements to confirm the diagnosis of asthma: demonstration of variable expiratory airflow limitation, documentation of reversible obstruction, and an exclusion of alternative diagnosis (Amin et al., 2014; Sawicki & Haver, 2016). Due to the inability of children under 6 years to perform - spirometry and peak flow NURSING 596 CULMINATING PROJECT 12 measures, asthma diagnosis in young children is typically based on the reported presence of symptoms and specific risk factors, such as family history and atopy (Huffaker & Phipatanakul, 2014; Sawicki & Haver, 2016; Szefler et al., 2014). The challenges associated with children under 6 years of age being able to perform these tests is attributed to their developmental cognitive stages and their difficulty with following complicated directions associated with spirometry and peak flow tests. Therefore, along with reported symptom patterns from parents, trials of asthma medications (for 2-3 months) such as bronchodilators and inhaled corticosteroids may also help to establish the diagnosis in these children. It is suggested that early initiation of such interventions (asthma medications) will not change the severity and clinical course of the disease (Link, 2014, Szefler et al., 2014; Wilson, Rand, Cabana et al., 2012). Other diagnostic tests to support the diagnosis of asthma include allergy skin testing. Allergy skin testing can be completed in order to establish potential triggers and aeroallergens, however the child must be in an asymptomatic stage (Chui, 2015). A chest radiograph or computed tomography scan may be completed in order to rule out any structural abnormalities or alternative diagnoses (GINA, 2015; Szefler et al., 2014). Biomarker testing is also suggested to confirm diagnosis, however due to the heterogeneity of the disease, biomarker testing has not been conclusively recommended (Bacharier & Guilbert, 2012; Szefler et al., 2014). Finally, exhaled nitric oxide analysis and quantitative analysis of expectorated sputum for eosinophilia are also two novel forms of monitoring asthma and airway inflammation, although they are not recommended by some (Bacharier & Guilbert, 2012; Chui, 2015; Sawicki & Haver, 2016). In summary, due to the limited diagnostic test availability practitioners are limited in their diagnostic resources for children less than 6 years who present with asthma symptoms and therefore must rely heavily on parents for subjective reports of symptom patterns and objective NURSING 596 CULMINATING PROJECT 13 medical examinations (Castro- Rodriguez, 2010). Parental Understanding and Health Literacy As mentioned, diagnosis in children less than 6 years of age is difficult due to limitations in their understanding and ability to follow direction, thus rendering traditional diagnostic modalities for asthma ineffective; the result is a practitioner who must rely solely on parent recollection of episodes in order to trend symptoms over a period of time. It is understood that the younger the child, the less information there is available to clinicians (Link, 2014). To combat difficulties with diagnosis in children within this age group, questionnaires and predictive indices have been suggested by authors, however because these instruments require caregiver assistance for completion, the recorded answers may not reflect the true nature of the underlying disease (Bacharier & Guilbert, 2014; Link, 2014; Szefler et al., 2014). As well, there is an ongoing challenge within pediatric questionnaire development to include developmentally appropriate language and concepts for both child and parent (Szefler et al., 2014). This is especially important when considering the health literacy of parents when reporting episodes, symptoms, treatments and interventions. Inadequate health literacy (HL) limits individuals\u00E2\u0080\u0099 abilities to access and pay for medical care, understand health care advice, weigh the risks and benefits of health decisions, follow recommendations for treatment, use medications correctly and safely, and understand the rights and responsibilities of health care (Shone, Conn, Sanders & Halterman, 2009). Parents with limited HL perceived their child as sicker, had a higher perceived asthma burden, reported poorer interactions with their child\u00E2\u0080\u0099s provider, reported more frequent emergency department use, worried more about their child\u00E2\u0080\u0099s health, and reported lower quality of life than did parents who had adequate HL (Abu- Shaheen, Nofal & Heena, 2016; Shone et al., 2009). Furthermore, low NURSING 596 CULMINATING PROJECT 14 HL has been strongly associated with lower socioeconomic status, lower education level, and other psychosocial factors (Shone et al., 2009). Parents with low levels of education were less able to represent their child\u00E2\u0080\u0099s asthma symptoms in ways providers expected, while parents with low HL were less able to effectively give or receive communications about the child\u00E2\u0080\u0099s asthma and symptoms patterns (Shone et al., 2009; Yoos, Kitsman, Henderson et al., 2007). More importantly, parents who struggle to fill out forms, questionnaires, and documents related to their child\u00E2\u0080\u0099s health were unable to convey important details about their child\u00E2\u0080\u0099s asthma, thus limiting the ability of the clinician to react and respond to episodes that may help lead to an eventual asthma diagnosis (Shone et al., 2009). As previously noted, HL is closely related to disease perception, with parental perceptions and practices being crucial for improving asthma outcomes in children (Abu-Shaheen et al., 2016; Zaraket, Al-Tannir et al., 2011). Unfortunately, several studies suggest many parents prefer not to disclose chronic or recurrent symptoms due to the stigma of asthma. Examples of such stigmas include the perceived inability to participate in certain sports due to the risk of exacerbation, as well as strategic avoidance of environments in an effort to avoid certain allergens and triggers. Parents often assume others will view their child as being chronically ill or in some way disabled when being diagnosed as asthmatic. Furthermore, the majority of parents believed their child had a chest allergy or dyspnea, rather than identifying the episodes as symptoms of asthma (Abe-Shaheen et al., 2016). This failure to disclose for fear of the stigmatization of chronic illness lead to poorer health outcomes and quality of life for children with asthma (Shone et al., 2009). These prevailing misperceptions of asthma are directly responsible for inefficient and inadequate practices taken for asthma control and diagnosis (Abu-Shaheen, 2016). NURSING 596 CULMINATING PROJECT 15 As Canada is a country defined by diverse populations, it is not uncommon for healthcare practitioners to encounter individuals who may have a limited knowledge of such colloquial terms as \u00E2\u0080\u009Cwheeze\u00E2\u0080\u009D. Moreover, as there is an influx of healthcare providers from diverse backgrounds where English is not their primary language, they too may have a limited understanding of the Anglophone word \u00E2\u0080\u009Cwheeze\u00E2\u0080\u009D and thus be reluctant to use the term (Abu-Shaheen et al., 2016). As the presence of \u00E2\u0080\u009Cwheeze\u00E2\u0080\u009D is a defining symptom in the process of diagnosing asthma in a child, the question of HL and understanding presents a dilemma. The practitioner must not only define the disease symptoms such as \u00E2\u0080\u009Cwheeze\u00E2\u0080\u009D but also define the meaning of symptoms related to asthma to both the parent and the child, further calling into question HL in the individual that is reporting and diagnosing symptom patterns. When interpreting the term \u00E2\u0080\u009Cwheeze\u00E2\u0080\u009D there is also a variation in the parental perception and definition of the word, despite primary language spoken. Specifically parents often report no wheeze; however, parents often use other words such as \u00E2\u0080\u009Ccrackly, squeaky, strangled, gasping, rasp, rattle, lisp, animal sounding and air noise\u00E2\u0080\u009D to describe their child\u00E2\u0080\u0099s respiratory symptoms (Callery, 2003, p. 59). Furthermore, some parents used more tangible features such as strangled or gasping; while others referred to the child\u00E2\u0080\u0099s overall appearance, chest movements, and chest vibrations (Callery, 2003). This further demonstrates the variability of perception when reporting asthma symptoms. In summation, early identification of children less than 6 (years of age) who are at greatest risk of developing asthma is a challenge for clinicians due to the complex nature of symptoms patterns, variations of symptoms between individuals, and a lack of reliable diagnostic tests (Panettieri et al., 2008). Objective measures of disease activity are limited and difficult to perform in preschool children due to their developmental cognitive stage (Panettieri et al., 2008). NURSING 596 CULMINATING PROJECT 16 Clinicians must rely heavily on parents and caregivers for information about symptom patterns and treatments. However, health literacy of parents must be considered when completing the complex interview process involved with the diagnosis of asthma in children less than 6. Therefore, for young children with recurrent symptoms suggestive of asthma, the use of a clinical index that incorporates risk elements, such as the Asthma Predictive Index (API) or Prevention and Incidence of Asthma and Mite Allergy (PIAMA) Risk Score might be the best indicator of probable asthma, thus resulting in more appropriate early diagnosis and effective asthma treatment (Panettieri et al., 2008). Review of Clinical Indices As mentioned, two predictive indices have been readily used in asthma care: the API and the PIAMA. Both tools have demonstrated positive effects on asthma outcomes by supporting communication between health care providers and parents (Hafkamp-de Groen et al., 2012). Moreover, the API and PIAMA risk score have been externally validated with results showing their generalizability and thus clinical applicability within various settings (Savenije, Kerkhof, Koppelman et al., 2012). Both of these predictive indices have been developed in an effort to prevent the inadequate treatment of childhood asthma in patients who potentially could be lost to follow-up by primary and secondary health care (Hafkamp-de Groen, Lingsma, Caudri et al., 2012). Despite the use of various predictive models which have been proposed to diagnose asthma, there are also complex and invasive tests or exams to aid in diagnosis. However, researchers suggest utilizing prediction tools such as bloodwork or bronchoalveolar lavage are not feasible given the low acceptance of drawing blood in various settings by both parents and children or potential for trauma related to these invasive procedures; as well as an identifiable lack of funding for laboratory tests which are focused on preventative healthcare within this NURSING 596 CULMINATING PROJECT 17 population (Castro-Rodriguez, 2010; Hafkamp-de Groen et al., 2012). Furthermore, specific serum biomarkers that have been linked to the development of asthma (such as IgE) have been shown to be affected by age and therefore are difficult to interpret in young children (Huffaker & Phipatanakul, 2014). Literature goes on to state that it is important to create relevant primary care driven predictive indices in order to capture children who begin to show asthma symptoms at a time when they regularly visit clinics for well-child care within the community setting (Fouzas & Brand, 2013; Hafkamp-de Groen et al., 2012; Hafkamp-de Groen et al., 2013). Moreover, there is an identified need for an asthma predictive index appraisal tool that supports health care professionals, specifically novice providers, in their decision making when a preschool aged child presents with asthma symptoms to their clinic as diagnosis is clearly complicated and challenging (Hafkamp-de Groen et al., 2012). API Analysis The API was developed by Castro-Rodriguez in 2000 in an effort to identify children who may develop asthma, and was created using data from 1,246 children in the Tucson Children\u00E2\u0080\u0099s Respiratory Study birth cohort (Castro-Rodriguez, 2010). The development of asthma in this predictive index is based on several factors found during the first 3 years of life and includes 1 of 2 major criteria (physician diagnosed eczema or parental asthma), or 2-3 minor criteria (physician diagnosis of allergic rhinitis, wheezing without colds, or peripheral eosinophilia >4% (Castro-Rodriguez, 2010; Castro-Rodriguez, 2013). Overall, the API is well validated and internationally supported although many clinicians remain skeptical about its utility in various settings (Huffaker & Phipatanakul, 2014). The stringent API is a simpler and less expensive tool than other more invasive modalities to identify children less than 6 years of NURSING 596 CULMINATING PROJECT 18 age who are at risk for developing asthma, and has exclusively been proven effective for use in younger children (<6 years of age) rather than older children (>6 years of age) (Castro-Rodriguez, 2010; Huffaker & Phipatanakul, 2014). Among the various predictive indices, the API is the only one which has been tested in different populations and in independent studies such as randomized clinical trials (Castro-Rodriguez, 2010). As a result, the API has the best combination of sensitivity, specificity, and predictive value of the indices and increases the probability of prediction of asthma by up to 4 times (Casto-Rodriguez, 2010; Castro-Rodriguez, 2013). Finally, this predicative index is multifunctional in that the features used to define a positive API score may also be successfully implemented into clinical practice by not only predicting disease development but also allowing practitioners to predict response to therapeutic treatment (Castro-Rodriguez, 2010; Hafkamp-de Groen et al., 2012). PIAMA Analysis The PIAMA Risk Score has been proposed as an instrument which predicts asthma at age 7\u00E2\u0080\u00938 years of age, using easily obtainable parameters and is assessed at the time of initial presentation of asthma-like symptoms (Hafkamp-de Groen et al., 2012). The PIAMA Risk Score discriminates between asthmatic and non-asthmatic children, and may be a suitable tool for use in well-child visits within community health settings (Caudri, 2009). The Risk Score includes parameters, and much like the API, is preferred above other prediction models such as blood tests, due to its less invasive and intrusive nature (Hafkamp-de Groen et al., 2012). The PIAMA Risk Score has 8 predictors: male sex, post-term delivery, parental education, parental inhalation medications (such as puffers), wheezing/dyspnea apart from colds, wheezing frequency, respiratory tract infections, and physician\u00E2\u0080\u0099s diagnosis of eczema (lifetime) and/or present eczematous rash (Hafkamp-de Groen et al., 2012; Hafkamp-de Groen et al., 2013; Castro-NURSING 596 CULMINATING PROJECT 19 Rodriguez, 2013). It utilizes a combination of parental report of symptom patterns, medical examinations, and health care records to assess each variable. It is the first study that reported post-term delivery as an independent predictor in any studied asthma prediction model (Hafkamp-de Groen et al., 2013). The discriminative ability of the PIAMA Risk Score is similar at different ages and in various ethnic and socioeconomic subgroups of preschool children which suggests good generalizability (Hafkamp-de Groen et al., 2013). Although the PIAMA risk score has good external validity, some studies call for the score to be reproduced in other populations and settings in order to assess its clinical relevance (Hafkamp-de Groen et al., 2013). Criticisms of the PIAMA Risk Score indicate that the predicted risks by the original Risk Score for having asthma at the age of 6 years were systematically overestimated (Hafkamp-de Groen et al., 2013). Compared to other predictive indices, the PIAMA index uses a more complicated approach, with odds ratios for individual predictors (Hafkamp-de Groen et al., 2013). Overall, the PIAMA system generates a more accurate predictive model, but the score is somewhat laborious to determine because the different factors involved have different weighted significance (Castro-Rodriguez, 2010). Moreover, the score relies heavily on accurate parental report of both personal and child health statuses at specific times, for example, wheezing frequency and use of parental inhaled medications at any point (Hafkamp-de Groen et al., 2013). Considering asthma is a complex disorder that is highly individual as well as multi-factorial, authors have suggested additional factors to consider which were otherwise omitted from the first risk model (Hafkamp-de Groen et al., 2012). These include: child\u00E2\u0080\u0099s ethnicity, preterm birth, sleeping problems due to asthma symptoms, physician visits due to asthma symptoms, wheezing patterns, allergy or general health (Hafkamp-de Groen et al., 2012). By identifying additional factors, authors highlight the complex nature of the disorder and identify that although there are NURSING 596 CULMINATING PROJECT 20 many common congruencies to the development of the illness, it is not always completely predictable. In summary, clinicians, particularly novice care providers, require modalities that simplify and streamline diagnosis yet they are wary of predictive indices for complex diseases which have not been validated in different settings, particularly in their own (Castro-Rodriguez, 2010). Practitioners must therefore instinctively use multiple parameters to make management decisions based on their own training and personal experience (Castro- Rodriguez, 2010). Before they begin using a predictive index, they need to be convinced by evidence based literature that it will ultimately improve the care of their patients. More specifically, even if an index is accurate, it must be easy to apply, validated in different populations and shown to improve patient outcomes in order to be used by busy clinicians (Castro- Rodriguez, 2010). Asthma Diaries It is well established predicting asthma is a complex and complicated process that involves many factors. In order to bridge the gap between parental report and accurate symptom portrayal, primary care practitioners can utilize symptom recording methods, such as diaries or questionnaires, to assist with diagnosis and appropriate treatment modalities. Current literature describes the use of diaries in many chronic diseases, specifically asthma and COPD. However, most diaries or journals are utilized and studied in individuals who have already been diagnosed and are currently receiving treatment and thus managing the knowledge, fears and feelings that are associated with their illness. In chronic disease management, it is important to regularly monitor disease status in an effort to capture disease burden on both the patient and caregivers (Cruz-Correia, Fonseca, Lima et al., 2007). Therefore, asthma diaries are useful for gathering clinical information ultimately resulting in the more effective care of patients, helps guide self-NURSING 596 CULMINATING PROJECT 21 management through symptom monitoring, better medication adherence, improves assessment and hones patient-provider communication (Cruz-Correia et al., 2007; Rhee, Fairbanks & Butz, 2014). When considering a potential asthma diagnosis, many studies rely on the use of questionnaires for answers regarding symptom patterns and treatments. Although standard respiratory questionnaires have shown good or satisfactory repeatability, they may not be appropriate for use with infants and preschool children where symptoms may differ due to developmental changes and where reports rely exclusively on proxy parents (Strippoli, Silverman, Michel & Kuehni, 2007). Many of these tools assume the asthma diagnosis is firmly established and caregivers are familiar with treatment approaches. Therefore, most asthma questionnaires are appropriate for use in the management process as most are focused on the global concept of asthma, which incorporates both current symptoms and risk of future attacks (Szefler et al., 2014; Wilson, Rand, Cabana et al., 2012). Furthermore, questionnaires completed by individuals in office have downfalls, one of which is long and often inaccurate recall duration as well as the integration of questions that often fail to capture the effect of the disease on things like sleep and daily activities, both of which are key indicators of symptom severity in asthma (Globe, Martin, Schatz et al., 2015; Voorend-van Bergen, Vaessen-Verberne, Landstra et al., 2014). Questionnaires require caregiver participation for completion, thus the recorded answers may not reflect the true nature of the underlying disease but rather an interpretation of it by their children and others around them (Szefler et al., 2014). Therefore, when choosing assessment methods that assist in predicting or treating chronic illnesses, it is important to utilize the most appropriate measure for the patient and illness in question. NURSING 596 CULMINATING PROJECT 22 Appropriateness of Diaries for Asthma Diaries are self-reported instruments used repeatedly to examine ongoing experiences, and offer practitioners the opportunity to investigate social, psychological, and physiological processes within everyday situations (Bolger, Davis & Rafaeli, 2003). The benefit of using the diary method is that they permit the examination of reported events and experiences in their natural, spontaneous context, and provide further information which is complementary to the patient perspectives traditionally being provided by means such as questionnaires and interviews (Bolger et al., 2003). Diaries have the advantages of being prospective and less reliant on parental memory, which is often skewed in the moment (Lam, Barr, Catherine et al., 2010). One of the greatest strengths of diary designs is they are excellent for studying temporal dynamics, specifically episodes or phenomena that occur unexpectedly and without provocation (Bolger et al., 2003). As well, with repeated exposure to diary questions and topics, participants\u00E2\u0080\u0099 understanding of a particular illness changes in several ways: they develop a more complex or enhanced understanding of the concept in question and the self-reflective recollection process becomes therapeutic in nature (Bolger et al., 2003). For chronic disease management such as asthma, patients are encouraged to actively participate in their care and treatment and to self-manage their health and illness (Kruijssen et al., 2015). The use of self-management diaries helps to improve individuals\u00E2\u0080\u0099 insight into their disease and subsequently increases empowerment and control over their illness (Kruijssen et al., 2015). From a patient perspective, self-management also acts as a way to gain more knowledge and insight into one\u00E2\u0080\u0099s disease but also as a means to utilize that insight to cope more effectively with the disease by recognizing an exacerbation and acting on it (Kruijssen et al., 2015). As a result, self-management approaches improve patients\u00E2\u0080\u0099 knowledge of their disease, treatment, and NURSING 596 CULMINATING PROJECT 23 increases their motivation and confidence that the disease can be controlled, thereby improving treatment adherence and symptom management (Kruijssen et al., 2015). This control can be best exemplified by the creation of an effective and open patient provider relationship early on in the treatment and diagnosis stage (In\u00E2\u0080\u0099t Veen, Mennema & Noort, 2012; Kruijssen et al., 2015). Though starting self-management diaries may require more time with patients, ultimately, it results in patients who have improved insight into their health, cope better with their chronic illness, participate and comply with treatment options and report an improved quality of life (Rhee, Fairbanks & Butz, 2014). As nurse practitioners and primary care providers, it is important to acknowledge, understand, and identify symptoms suggestive of asthma that may deviate beyond just coughing and wheezing (Rhee, Fairbanks & Butz, 2014). As traditional questionnaires can ultimately allow for flawed recall on the part of a stressed, overwhelmed or scared parent, it is incumbent upon us to create tools allowing for open and accurate portrayal of symptoms and to decrease reporter burden. By creating My Breathing Buddy, an event contingent tool requiring participants to provide a self-reported notation each time an event in question occurs, we enable the assessment of individual episodes which would not necessarily be captured by fixed or random interval assessments such as questionnaires; thus empowering patients and parents alike. Design of My Breathing Buddy Although design aspects of journals and diaries were not frequently highlighted within the literature, salient points were recommended by a qualitative study focused on adolescent use of diaries and their perception of asthma exacerbations and management. One such suggestion was it is important to include questions that highlight activity limitations that are a direct consequence of debilitating symptoms related to asthma (Rhee et al., 2014). Open-ended NURSING 596 CULMINATING PROJECT 24 questions that were not too direct allowed for optimal recollection and freedom of interpretation (Rhee et al., 2014). Furthermore, the integration of pointed questions limited the ability of participants to recall results in retrospective aggregate responses that potentially could reflect a faulty representation of an illness or phenomena of interest (Bolger et al., 2003). Diaries or journals must also allow for short entries which take several minutes to complete and thus encourage prompt participation (Rhee et al., 2014). The design of the diary must have ample free writing space that minimizes limitations and allows for freedom of responses (Bolger et al., 2003). This allows for recognition of temporal patterns and ability to acknowledge unconventional associations between symptoms and triggers (Bolger et al., 2003). Language within a diary should be kept simple and understandable in an effort to avoid confusions and decrease the potential for reporter burden associated with completing the task. This becomes especially important when being used in stressful situations such as an emergency department visit where actions are taken quickly and multiple providers are involved in care. Lastly, the integration of a space where care providers can complete information about interventions and diagnoses should be included to avoid unintentional omissions in recall by parents or caregivers. Limitations to Diary Use There are several limitations that exist when considering the use of diaries. One such limitation of paper diaries includes participants forgetting to complete diary entries, and thus provider uncertainties regarding compliance and retrospection errors; this is also referred to as backfilling of a journal over a period of time (Lam et al., 2010). Retrospective error is further defined as the moment when participants rely on a reconstruction or fabrication to complete missed entries, thus potentially defeating the main benefit of diaries, namely their ability to NURSING 596 CULMINATING PROJECT 25 obtain accurate information (Bolger et al., 2003). An example of this would be participants completing the diary minutes before a medical appointment in an effort to avoid being reprimanded for noncompliance. Another important potential constraint is the burden of recording that is placed on the participant (Bolger et al., 2003). A contributing factor to this is the requested frequency, detail, and duration of recording, and the requested context in which the recordings are made (Lam et al., 2010). That is, the more specific and detailed the entries must be, the more burden that is placed on the parent or participant. However, unexpectedly there was a discrepancy identified by Strippoli et al. (2007) between fathers who reported symptoms versus mothers who reported symptoms to providers. Specifically, when fathers responded, significantly lower repeatability of results was found for questions centered around current symptoms of asthma and infant care. Authors attributed this to mothers generally being the primary caregivers at home on a daily basis whereas fathers generally take time off work and are present when children are ill and are otherwise not actively participate in the daily home activities and care (Strippoli et al., 2007). The result of the more consistent presence of mothers is that, generally, there is a more accurate portrayal of the child\u00E2\u0080\u0099s daily health status in regards to exacerbations and triggers of asthma (Strippoli et al., 2007). In an effort to avoid the inevitable difficulties associated with remembering to use the tool as well as the potential for losing the diary, many studies suggested the integration of e-diaries rather than paper diaries. Diaries require commitment and dedication for their completion on the part of both patient and provider in that detailed instructions and explanations must be provided prior to use, as well as continual support on the part of the practitioner in the event the diary is lost or questions arise. By supporting the parent and patient, nurse practitioners can develop a healthy and open therapeutic relationship in regards to potential NURSING 596 CULMINATING PROJECT 26 asthma symptoms, treatment, diagnosis and management that potentially combats or reduces caregiver burnout and ineffective coping. Implications for Practice Supporting parents and clients through the anxiety inducing process of discovering a potentially life changing chronic illness should always be a Nurse Practitioner\u00E2\u0080\u0099s foremost priority. Nurse Practitioners must understand early recognition and treatment of symptoms closely resembling asthma will dramatically impact the patient and family in a positive way. As well, a collaborative and trusting relationship between family and practitioner must be established in order to successfully manage the potential disease in the long term (Link, 2014). Parents of children who have been diagnosed with asthma often identify there is a disconnect in communication between practitioners and parents. Often, the two groups disagree in the amount of time dedicated to asthma education in the office with conversations surrounding medication side effects and treatments often being neglected; furthermore, practitioners often overestimate the extent of knowledge parents already possess regarding the illness itself, potentially limiting the amount of teaching being done because of assumptions surrounding existing parental knowledge (Wendling, 2006; Yoo et al., 2007). The result of these discrepancies in education on the part of parents and practitioners is poor asthma treatment compliance, more frequent symptoms, and a greater use of Emergency Departments (Wendling, 2006). Therefore, asthma education should begin early, specifically before the diagnosis is made. Parents are often overwhelmed by the potential diagnosis and their capacity for absorption of education is limited during this time; capturing the moment to learn is imperative. Education for parents and patients should be supportive and holistic. Both stakeholders should have the opportunity to express their perspectives and concerns about their potential NURSING 596 CULMINATING PROJECT 27 diagnoses freely. Parents and patients need to be introduced early on to the language surrounding asthma, such as bronchodilators, inhalers, triggers and wheeze in order to increase understanding, awareness and empowerment. Link (2014) identifies asthma care can only be successful if long term relationships are established among patient, parent and asthma care team. By integrating an autonomous diary into therapeutic relationships, where parents can take control of their child\u00E2\u0080\u0099s care and documentation, communication becomes opened and improved. Frequent follow up should be encouraged which integrates concerns from both the parent and patient and discusses in detail the results that are recorded in the diary. Discussions should be tailored to the individual needs of the patient based on risk, impairment, and need for additional counselling and education (Link, 2014). Health literacy should be addressed by the Nurse Practitioner in the early stages of disease presentation. Reasons for this are to enhance understanding and competence around illness and health care navigation and to identify barriers to appropriate care, for example clearly defining what is a wheeze or reinforcing the correct usage of primary and tertiary health care centers. By using a diary called My Breathing Buddy, cultural perceptions of the disease can be established in the early stages of diagnosis by addressing beliefs surrounding the meaning of the word wheeze and the stigma attached to illness presentation. This tool promotes and encourages open dialogue between care providers, patients, and families that will ultimately end in optimal outcomes for the patients. This tool also presents a vehicle for practitioners to introduce frequently used terms related to asthma to parents and patients, as well as begin a conversation around what traditionally accompanies a diagnosis of asthma, such as various tests and treatments. By doing so, the Nurse Practitioner can assist families in the detection and response to fluctuations in breathing which eventually allows parents to act with confidence and assurance in the care of their asthmatic child. This NURSING 596 CULMINATING PROJECT 28 empowerment therefore establishes an interactive partnership between patient, parent and provider which is collaborative, holistic and supportive (Link, 2014). Creation of My Breathing Buddy As mentioned, My Breathing Buddy is a tool which functions as a travelling record or chart. The development of such a tool takes into account usability and applicability for both parent and patient; therefore, this tool must be appropriate for both target users. To start, the brightly colored cover will be inviting, as well as easily recognizable in times when a parent may be prone to forgetting such tools, for example in a stressful moment where the parent is quickly leaving the household to go to a clinic or an emergency department. The title page will be arranged in such a way that graphics on the front cover are pleasant and non-cluttered. The inside page will include a small description about the tool and how to properly use it, followed by a page that includes the child\u00E2\u0080\u0099s demographic information including name, home telephone number, date of birth and gender at birth as well as a notation that, if found, the tool can be returned to a specific location, be it the home or clinic. Nurse Practitioners who are dispensing this tool must ensure parents are informed of the potential for breach of confidentiality if lost; therefore, it is up to parents to disclose as much or as little personal information as they feel comfortable recording within the demographics page. The next page will include birth history, including: gestational age, birth weight, complications during the pregnancy, vaginal or cesarean birth, hospitalizations after birth, previous medical history, breast feeding history and known allergies. The next page will include family medical history such as mother, father or sibling(s) and their medical conditions. Conditions specifically highlighted are ones linked with atopy such as eczema (diagnosed by a healthcare practitioner) or asthma (persistent and/or childhood), as well as use of inhaler medications and presence of hay fever. This page will also highlight the NURSING 596 CULMINATING PROJECT 29 environment in which the child lives, paying close attention to exposure cigarette smoke, daycare attendance, pet avoidance and current family pets. In order to encourage participation of the child in the history portion of the diary, there will be a consistent presence of a mascot throughout the tool. The mascot's name is \u00E2\u0080\u009CBuddy the Diagnosis Detective\u00E2\u0080\u009D and is in the form of a friendly dog that will encourage children to participate in the use of the diary. The name \u00E2\u0080\u009CBuddy\u00E2\u0080\u009D is strategic as it is not gender specific and implies the tool is friendly and non-intimidating. The diary or tool will then lead into separate sections identified by colorful dividers labeled as: home, clinic and hospital. Dividing the symptom diary component, will allow for quick identification by both parent and practitioner during the recording and interviewing processes. Also, each section will be punctuated with large-scale graphics that can be used as a coloring book for the child when waiting to see a physician or Nurse Practitioner; thus providing a multipurpose component. By creating an interactive tool for both parents and children, the aim is to incentivize the use of the diary. Within each section, there will be simple lead-in phrases (such as, \u00E2\u0080\u009CToday, my child had a cough \u00E2\u0080\u00A6\u00E2\u0080\u009D) alluding to the symptoms of asthma, followed by large blank spaces intended to give parents the opportunity to fill in more information they deem as relevant and important. Within the clinic section of the diary, each page is dedicated to one singular visit. When a parent brings their child to the primary care practitioner for respiratory symptoms, prior to meeting the practitioner they will have completed the clinic pages either at home or in the waiting room. This information will include the date, time and specifics regarding the development of symptoms and signs that compelled them to seek help; specifically: when did the symptoms start; was there any wheezing that the parent could hear; was there rhinorrhea, cough, disturbed sleeping, or rash? In these sections, there will be an NURSING 596 CULMINATING PROJECT 30 abundance of free space to allow for parents to further expand on any symptoms that were omitted in the lead-in phrases. There will be a section labeled Treatment on the same page, which would be completed either before visiting the clinic or during, that explains any medical treatments the child has undergone; for example: nebulizers or puffers. Finally, each entry will finish with a section that the primary care provider completes. This portion of the page will be called Care Provider Impression in which a working diagnosis is recorded and there will be a sub-section for completion which states \u00E2\u0080\u009Cwheeze present\u00E2\u0080\u009D or \u00E2\u0080\u009Cwheeze absent\u00E2\u0080\u009D and can easily be circled by the Nurse Practitioner or physician. All language used in this tool will be simple and easy to understand. Each section will be similar in its format so as not to confuse the reader and the participant, thus preventing inappropriate or inaccurate use of the diary. Each section will contain multiple episode pages that allow for ample recording room. At the end of the diary, there will be large lined pages labeled \u00E2\u0080\u009CNotes\u00E2\u0080\u009D where parents can record questions, concerns or symptom outliers they may have noted. Despite the uncomplicated form and function of this tool, its use could potentially be daunting and intimidating to the novice parent. In order to create a therapeutic and supportive environment to families that may be experiencing new challenges, the Nurse Practitioner must foster an environment of trust and understanding. In order to do this, it is important the Nurse Practitioner explain each page in detail when dispensing this tool. The Nurse Practitioner must emphasize this tool is meant to assist in the diagnosis but will not be the sole piece of diagnostic evidence. Parents must be reassured that this tool is meant to lift the burden of recollection from the parent and child and to help support them through a difficult and potentially life-changing experience. NURSING 596 CULMINATING PROJECT 31 Conclusion In summary, asthma is a complex reversible obstructive airway disease involving many variable symptoms and triggers. The presence of multiple risk factors such as genetics, the presence of atopy as well as early symptoms of wheeze can help predict illness development. Diagnosis of asthma is made using several modalities including spirometry and peak flow, both of which cannot be reliably completed in children less than 6 years old. Various predictive indices have been identified to help streamline diagnoses and thus avoid airway remodeling and improve overall lung function. However, some of these indices are not appropriate as health literacy and disease understanding varies among many individuals and thus impacts the reporting patterns of symptoms. Nurse Practitioners can support this process by utilizing tools such as diaries and journals that chronical symptom patterns and treatments received in various setting in order to support parents and patients as well as appropriately diagnose individuals in a timely manner. By creating a diary entitled My Breathing Buddy, Nurse Practitioners, can introduce parents and patients to asthma in a more holistic approach, and eventually empower parents to take control of their child\u00E2\u0080\u0099s health in a more comprehensive manner. NURSING 596 CULMINATING PROJECT 32 References Abu-Shaheen, A. K., Nofal, A., & Heena, H. (2016). Parental Perceptions and Practices toward Childhood Asthma. Biomed Research International, 1-7. doi:10.1155/2016/6364194. Akinbami LJ, Sullivan SD, Campbell JD, Grundmeier RW, Hartert TV, Lee TA, et al. (2012). Asthma outcomes: Healthcare utilization and costs. The Journal Of Allergy And Clinical Immunology.129(Suppl):S49-64. \u00E2\u0080\u00A8 Amin, P., Levin, L., Epstein, T., Ryan, P., LeMasters, G., Khurana Hershey, G., . . . Bernstein, D. I. (2014). Optimum predictors of childhood asthma: Persistent wheeze or the asthma predictive index? The Journal of Allergy and Clinical Immunology. in Practice, 2(6), 709-715.e2. doi:10.1016/j.jaip.2014.08.009. Bacharier L.B., Guilbert T.W. (2012). Diagnosis and management of early asthma in preschool- aged children. The Journal of Allergy and Clinical Immunology. 130:287-98. Bisgaard, H., & B\u00C3\u00B8nnelykke, K. (2010). Long-term studies of the natural history of asthma in childhood. Journal of Allergy and Clinical Immunology, 126(2), 187-197. doi:10.1016/j.jaci.2010.07.011. Bolger, N., Davis, A., & Rafaeli, E. (2003). Diary methods: Capturing life as it is lived. Annual Review of Psychology, 54(1), 579-616. doi:10.1146/annurev.psych.54.101601.145030. Brashers, V.L. in McCance, K. L., & Huether, S. E. (2010). Pathophysiology: The Biologic Basis for Disease in Adults and Children (6th ed.). Maryland Heights, MO: Mosby Elsevier. Brunekreef, B., Smit, J., de Jongste, J., Neijens, H., Gerritsen, J., Postma, D., . . . van Strien, R. (2002). The prevention and incidence of asthma and mite allergy (PIAMA) birth cohort study: Design and first results. Pediatric Allergy and Immunology, 13(s15), 55-60. doi:10.1034/j.1399-3038.13.s.15.1.x. NURSING 596 CULMINATING PROJECT 33 Callery, P. (2003). Parents' accounts of their children's respiratory symptoms showed a range of interpretations. Evidence Based Nursing, 6(2), 59. Castro-Rodriguez J.A., Holberg C.J., Wright A.L., Martinez, F.D. (2000). A clinical index to define risk of asthma in young children with recurrent wheezing. American Journal of Respiratory and Critical Care Medicine, 162:1403-6. \u00E2\u0080\u00A8 Castro-Rodriguez, J. (2010). The asthma predictive index: A very useful tool for predicting asthma in young children. Journal of Allergy and Clinical Immunology, 126(2), 212- 216. doi:10.1016/j.jaci.2010.06.032. Castro-Rodriguez, J. A. (2013). The necessity of having asthma predictive scores in children. Journal of Allergy and Clinical Immunology, 132(6), 1311-1313. doi:10.1016/j.jaci.2013.09.006. Caudri, D. (2009). Predicting the long-term prognosis of children with symptoms suggestive of asthma at preschool age. Journal of Allergy and Clinical Immunology, 124(5), 903- 910.e7. doi:10.1016/j.jaci.2009.06.045. Caudri, D., Wijga, A., A Schipper, C. M., Hoekstra, M., Postma, D. S., Koppelman, G. H., & ... de Jongste, J. C. (2009). Predicting the long-term prognosis of children with symptoms suggestive of asthma at preschool age. Journal Of Allergy And Clinical Immunology, 124(5), 903-10.e1-7. doi:10.1016/j.jaci.2009.06.045. Chui, A.M. in Marcdante, K. M., & Kliegman, R. M. (2015). Nelson Essentials of Paediatrics (7th ed., pp. 273-282). Philideplphia, PA: Elsevier Saunders. Cruz-Correia, R., Fonseca, J., Lima, L., Araujo, L., Delgado, L., Castel- Branco, M. G., & Costa- Pereira, A. (2007). Web-based or paper-based self-management tools for asthma- NURSING 596 CULMINATING PROJECT 34 Patients' opinions and quality of data in a randomized crossover study. Studies in Health Technology and Informatics, 127, 178\u00E2\u0080\u0093189. Diaz-Vazquez C, Torregrosa-Bertet MJ, Carvajal-Uruena I, Cano-Garcinuno A, Fos-Escriva E, Garcia-Gallego A, et al. (2009). Accuracy of ImmunoCAP Rapid in the diagnosis of allergic sensitization in children between 1 and 14 years with recurrent wheezing: the IReNE study. Journal of Pediatric Allergy Immunology. 20:601-9. Ducharme, F. M., Dell, S. D., Radhakrishnan, D., Grad, R. M., Watson, W. T., Yang, C. L., & Zelman, M. (2015, October). Diagnosis and management of asthma in preschoolers: A Canadian Thoracic Society and Canadian Paediatric Society position paper. In Canadian Paediatric Society. Retrieved September 28, 2016, from http://www.cps.ca/en/documents/position/asthma-in-preschoolers#ref5. Global Initiative for Asthma (GINA) (2015). Pocket Guide for Asthma Management and Prevention: For Children 5 Years and Younger. Retrieved from http://ginasthma.org/pocket-guide-for-asthma-management-and-prevention-in-children-5- years-and-younger/ on January 11, 2017. Globe, G., Martin, M., Schatz, M., Wiklund, I., Lin, J., von Maltzahn, R., & Mattera, M. S. (2015). Symptoms and markers of symptom severity in asthma--content validity of the asthma symptom diary. Health and Quality of Life Outcomes, 13(1), 21-21. doi:10.1186/s12955-015-0217-5. Fouzas, S., & Brand, P. (2013). Predicting persistence of asthma in preschool wheezers: crystal balls or muddy waters? Paediatric Respiratory Reviews, 14(1), 46-52. doi:10.1016/j.prrv.2012.08.004. NURSING 596 CULMINATING PROJECT 35 Hafkamp-de Groen, E., Lingsma, H. F., Caudri, D., Wijga, A., Jaddoe, V. W., Steyerberg, E. W., & ... Raat, H. (2012). Predicting asthma in preschool children with asthma symptoms: study rationale and design. BMC Pulmonary Medicine, 12(1), 65. doi:10.1186/1471- 2466-12-65. Hafkamp-de Groen, E., Lingsma, H. F., Caui, D., Levie, D., Wijga, A., Koppelman, G. H., . . . Raat, H. (2013). Predicting asthma in preschool children with asthma-like symptoms: Validating and updating the PIAMA risk score. Journal of Allergy and Clinical Immunology, 132(6), 1303-+. doi:10.1016/j.jaci.2013.07.007. Huffaker, M. F., & Phipatanakul, W. (2014). Utility of the Asthma Predictive Index in predicting childhood asthma and identifying disease-modifying interventions. Annals of Allergy, Asthma & Immunology, 112(3), 188-190. doi:10.1016/j.anai.2013.12.00.1. In\u00E2\u0080\u0099t Veen J, Mennema B., & Van Noort E. (2012) Online self-management in COPD or asthma: with or without the healthcare provider? European Respiratory Journal, 40(Suppl 56):P1284.\u00E2\u0080\u00A8 Klinner, M. D., Nelson, H. S., Price, M. R., Adinoff, A. D., Leung, D. Y. M., & Mrazek, D. A. (2001). Onset and persistence of childhood asthma: Predictors from infancy. Pediatrics, 108(4), e69-e69. doi:10.1542/peds.108.4.e69. Kruijssen, V. V., Staa, A. V., Dwarswaard, J., Mennema, B., Adams, S. A., & Veen, J. (2015). Use of Online Self-Management Diaries in Asthma and COPD: A Qualitative Study of Subjects' and Professionals' Perceptions and Behaviors. Respiratory Care, 60(8), 1146- 1156. doi:10.4187/respcare.03795. Lam, J., Barr, R. G., Catherine, N., Tsui, H., Hahnhaussen, C. L., Pauwels, J., & Brant, R. (2010). Electronic and paper diary recording of infant and caregiver behaviors. Journal of NURSING 596 CULMINATING PROJECT 36 Developmental and Behavioral Pediatrics: JDBP, 31(9), 685. doi:10.1097/DBP.0b013e3181e416ae. Link, H. W. (2014). Pediatric asthma in a nutshell. Pediatrics in Review, 35(7), 287-298. doi:10.1542/pir.35-7-287. Looijmans-van den Akker, I., van Luijn, K., & Verheij, T. (2016). Overdiagnosis of asthma in children in primary care: a retrospective analysis. British Journal of General Practice, 66(644), e152-e157. doi:10.3399/bjgp16X683965. Melnyk, B., Feinstein, N., Moldenhouer, Z., & Small, L. (2001). Coping in parents of children who are chronically ill: strategies for assessment and intervention. Pediatric Nursing, 27(6), 548-573. Panettieri, R. J., Covar, R., Grant, E., Hillyer, E. V., & Bacharier, L. (2008). Natural history of asthma: persistence versus progression-does the beginning predict the end?. The Journal Of Allergy And Clinical Immunology, 121(3), 607-613. doi:10.1016/j.jaci.2008.01.006. Revicki, D., & Weiss, K. B. (2006). Clinical assessment of asthma symptom control: Review of current assessment instruments. Journal of Asthma, 43(7), 481-487. doi:10.1080/02770900600619618. Saglani S, Payne DN, Zhu J, Wang Z, Nicholson AG, Bush A, et al. (2007). Early detection of airway wall remodeling and eosinophilic inflammation in preschool wheezers. American Journal of Respiratory and Critical Care Medicine. 176:858-64. Savenije, O. M., Kerkhof, M., Koppelman, G. H., & Postma, D. S. (2012). Predicting who will have asthma at school age among preschool children. Journal of Allergy and Clinical Immunology, 130(2), 325-331. doi:10.1016/j.jaci.2012.05.007. NURSING 596 CULMINATING PROJECT 37 Sawicki, G. & Haver, K. (2016). Asthma in children younger than 12 years: Epidemiology and pathophysiology. UpToDate. Retrieved from https://www.uptodate.com/contents/asthma- in-children-younger-than-12-years-epidemiology-and-pathophysiology?source=see_link on January 11, 2017. Shone, L. P., Conn, K. M., Sanders, L., & Halterman, J. S. (2009). The role of parent health literacy among urban children with persistent asthma. Patient Education and Counseling, 75(3), 368-375. doi:10.1016/j.pec.2009.01.004. Singh A.M., Moore P.E., Gern J.E., Lemanske R.F. Jr, Hartert T.V. (2007). Bronchiolitis to asthma: a review and call for studies of gene-virus interactions in asthma causation. Am J Respir Crit Care Med. 175:108-19. Spahn, J. D., & Covar, R. (2008). Clinical assessment of asthma progression in children and adults. Journal of Allergy and Clinical Immunology, 121(3), 548-557. doi:10.1016/j.jaci.2008.01.012. Szefler, S. J., Chmiel, J. F., Fitzpatrick, A. M., Giacoia, G., Green, T. P., Jackson, D. J., & ... Raissy, H. H. (2014). Asthma across the ages: knowledge gaps in childhood asthma. Journal of Allergy and Clinical Immunology, 133(1), 3-13. doi:10.1016/j.jaci.2013.10.018. Voorend-van Bergen, S., Vaessen-Verberne, A. A., Landstra, A. M., Brackel, H. J., van den Berg, N. J., Caudri, D., & ... Pijnenburg, M. W. (2014). Monitoring childhood asthma: web-based diaries and the asthma control test. Journal of Allergy and Clinical Immunology, 133(6), 1599-605.e2. doi:10.1016/j.jaci.2013.10.005. NURSING 596 CULMINATING PROJECT 38 Wendling, P. (2006). Asthma Survey Reveals Communication Gaps Between Physicians and Parents. Clinical Psychiatry News. Retrieved from http://bit.ly/2iCboja on January 22, 2017. Wilson S.R., Rand C.S., Cabana M.D., Foggs M.B., Halterman J.S., Olson L., et al. (2012). Asthma outcomes: quality of life. Journal of Allergy and Clinical Immunology. 129(Suppl): S88-123. Yoos, H. L., Kitzman, H., Henderson, C., McMullen, A., Sidora-Arcoleo, K., Halterman, J. S., & Anson, E. (2007). The impact of the parental illness representation on disease management in childhood asthma. Nursing Research, 56(3), 167-174. doi:10.1097/01.NNR.0000270023.44618.a7. Zaraket, R., Al-Tannir, M. A., Bin Abdulhak, A. A., Shatila, A., & Lababidi, H. (2011). Parental perceptions and beliefs about childhood asthma: a cross-sectional study. Croatian Medical Journal, 52(5), 637-643. NURSING 596 CULMINATING PROJECT 39 Appendix A PIAMA Risk Score Factors1 1. Sex (Male=2, Female = 0) 2. Preterm birth (<37 weeks) (yes=1, no= 0) 3. Medium/low parental education (at least one parent) (yes= 1, no= 0) 4. Parental asthma (yes= 4, no=0) 5. Wheezing frequency a. 1-3 times/year (yes= 4, no=0) b. greater than or equal to four times/year (yes=7, no=0) 6. Wheezing/dyspnea apart from colds (yes=2, no=0) 7. Respiratory tract infections* a. 1-2 times/year (yes=1, no=0) b. greater than or equal to 3 times/year (yes=1, no=0) 8. Doctor\u00E2\u0080\u0099s diagnosis of eczema and eczematous rash present (yes=6, no=0) Total:_______ PIAMA RISK SCORE RISK OF ASTHMA BY SCHOOL AGE <7 <5% 8-15 6%-22% >16 25%-60% 1. Brunekreef, B., Smit, J., de Jongste, J., Neijens, H., Gerritsen, J., Postma, D., . . . van Strien, R. (2002). The prevention and incidence of asthma and mite allergy (PIAMA) birth cohort study: Design and first results. Pediatric Allergy and Immunology, 13(s15), 55-60. doi:10.1034/j.1399-3038.13.s.15.1.x. *Defined as a parental report of number of serious respiratory tract, nose, throat and/or ear infections was defined based on parental reports on the number of doctor\u00E2\u0080\u0099s office visits cause by child\u00E2\u0080\u0099s fever in combination with cough, a runny or blocked nose, or earache in last 12 months (Hafkamp-de Groen et al., 2013). NURSING 596 CULMINATING PROJECT 40 Appendix B Asthma Predictive Index1 MAJOR CRITERIA MINOR CRITERIA PARENTAL MD ASTHMA \u00C2\u00A7 MD allergic rhinitis \u00E2\u0088\u0086 MD ECZEMA \u00C2\u00A7\u00C2\u00A7 Wheezing apart from colds Eosinophilia Criteria: Loose index for the prediction of asthma: early wheezer plus at least one of the two major criteria or two of three minor criteria. Stringent index for the prediction of asthma: early frequent wheezer plus at least one of the two major criteria or two of three minor criteria. \u00C2\u00A7 History of physician diagnosis of asthma \u00C2\u00A7\u00C2\u00A7 Physician diagnosis of atopic dermatitis at age 2 or 3 \u00E2\u0088\u0086 Physician diagnosis of allergic rhinitis at age 2 or 3 1. Castro-Rodriguez, J. (2010). The asthma predictive index: A very useful tool for predicting asthma in young children. Journal of Allergy and Clinical Immunology, 126(2), 212- 216. doi:10.1016/j.jaci.2010.06.032. Running head: NURSING 596 CULMINATING PROJECT 1 A DIARY FOR PARENTS OF CHILDREN WITH SUSPECTED ASTHMA by JODI HARRIS BScN, Kwantlen Polytechnic University, 2012 A CULMINATING PROJECT SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF NURSING \u00E2\u0080\u0093 NURSE PRACTITIONER in THE FACULTY OF GRADUATE AND POSTDOCTORAL STUDIES (School of Nursing) THE UNIVERSITY OF BRITISH COLUMBIA Vancouver April/2017 \u00C2\u00A9 Jodi Harris, 2017 NURSING 596 CULMINATING PROJECT 2 Abstract Asthma is one of the most common illnesses in childhood. The development of asthma occurs early in life and is associated with many risk factors. However, identification and diagnosis of asthma in children is challenging. This is due to variability of disease presentations, as well as the inability of some children to perform diagnostic tests essential for accurate diagnosis. Therefore, it has been recommended a tool be created to assist in the diagnosis of asthma in children less than 6 years old. Given this salient recommendation, the purpose of this project is to develop a symptom mapping tool (in the form of a diary) Nurse Practitioners can offer to parents of children under 6 years old with suspected asthma, who have not yet been diagnosed. This diary will act as a travelling chart that serves to document episodes mirroring the development of asthma. In order to create this tool, a comprehensive literature review was completed and as a result, My Breathing Buddy was created. This tool helps parents provide pertinent diagnostic information regarding symptoms related to upper respiratory illnesses that mimic asthma. Ultimately, this tool aims to empower parents and integrates both the patient and parent into the diagnostic process. Keywords: Asthma; Diagnosis; Child; Children, Preschool; Pediatrics, Respiratory Tract Diseases; Chronic Disease; Health Promotion NURSING 596 CULMINATING PROJECT 3 Table of Contents Methods\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6... 6 Asthma as a Disease\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6 7 Risk Factors for Asthma\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6..8 Symptoms and Triggers\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6.. 9 Diagnosis\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6... 11 Parental Understanding and Health Literacy\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6 13 Review of Clinical Indices\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6 16 API Analysis\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6. 17 PIAMA Analysis\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6... 18 Asthma Diaries\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6.. 20 Appropriateness of Diaries for Asthma \u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6... 22 Design of My Breathing Buddy.\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6...\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6 23 Limitations to Diary Use\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6... 24 Implications for Practice\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6... 26 Creation of My Breathing Buddy\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6...\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6...28 Conclusion\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6 31 References\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6..32 Appendix A\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6..\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6..39 Appendix B\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A6\u00E2\u0080\u00A640 NURSING 596 CULMINATING PROJECT 4 Nursing 596 Culminating Project Literature Review: A Diary for Parents of Children with Suspected Asthma Asthma is one of the most common chronic childhood illnesses (Gina, 2015; Looijmans-van den Akker, Luijn & Verheij, 2016; Spahn & Covar, 2008). It is a disease characterized by reversible airflow obstruction, bronchial hyper-reactivity, and inflammation (Brashers, 2010). Asthma often results from the complex interaction between a host\u00E2\u0080\u0099s genetics and their environment (Szefler et al, 2014). Exposure to antigens found in the environment creates a cascading immune response within the lung tissue that leads to alterations in the inflammatory pathways, resulting in an initial presentation of chest constriction, expiratory wheezing, dyspnea, nonproductive coughing, prolonged expiration, tachycardia, and tachypnea (Brashers, 2010; Spahn & Covar, 2008; Szefler et al., 2014). The age of onset of asthma is variable, but generally occurs early in life and is associated with many known risk factors; early identification in childhood may help prevent the development of future lung abnormalities (such as the remodeling of airways) in adulthood (Brashers, 2010; Huffaker & Phipatanakul, 2014; Spahn & Covar, 2014). Asthma is a disease process that changes throughout life with a peak prevalence during childhood, with some children outgrowing the disease while others experience subsequent relapses and remissions, all often occurring before 6 years of age (Bisgaard & B\u00C3\u00B8nnelykke, 2010; Ducharme, et al., 2015; Looijmans-van den Akker et al., 2016). Its prevalence in Canada has been increasing over the past ten years while the incidence of asthma attacks remains stable (Statistics Canada, 2016). Practitioners should base diagnosis on a compatible history, which includes recurrent episodes of wheezing, cough, difficulty breathing, and chest tightness, as well as a physical exam (BC Guidelines, 2015). However, diagnosis in children who are less than 6 years of age is difficult due to the absence of ability to complete diagnostic tests such as NURSING 596 CULMINATING PROJECT 5 pulmonary function tests and peak expiratory flow tests, both of which are essential for the correct diagnosis of asthma (BC Guidelines, 2015; Looijmans-van den Akker, et al. 2016; Panettieri et al., 2008). Researchers suggest a diagnosis of asthma in children requires objective documentation of signs and symptoms or convincing parent reported symptoms of airflow obstruction (Ducharme, et al., 2015). However, many children present to health care professionals with an absence of traditional symptoms characteristic of asthma (such as wheezing), resulting in providers relying heavily upon parental reports of symptomatic responses to trial medications and past treatments (Ducharme, et al., 2015). More importantly, children with undiagnosed asthma utilize healthcare services more frequently than children with appropriately diagnosed and managed asthma (Szefler et al., 2014). Therefore, knowledge pertaining to other factors such as emergency department use, hospitalizations, and unscheduled clinic visits are instrumental for the assessment and diagnosis of asthma in the pediatric population (Szefler et al., 2014). This diagnostic challenge has resulted in many practitioners becoming reluctant to diagnose asthma in children under 6 years of age, and instead resort to utilizing alternative diagnoses such as \u00E2\u0080\u0098viral induced wheeze,\u00E2\u0080\u0099 \u00E2\u0080\u0098bronchospasm,\u00E2\u0080\u0099 or \u00E2\u0080\u0098reactive airway disease\u00E2\u0080\u0099 (Ducharme et al., 2015), thus contributing to suboptimal management. Practitioners cannot effectively predict or prevent disease, and the current treatment of asthma and other respiratory disorders in children is viewed as inadequate and cumbersome (particularly if early in life), resulting in disease fatigue on the part of both the parent and child (Bisgaard & B\u00C3\u00B8nnelykke, 2010; Link, 2014). Disease fatigue is described as the persistent overwhelming condition that parents experience when caring for children with chronic illnesses (Melnyk, Forehand, Moldenhouer & Small, 2001). The reality of many chronic illnesses is they are fraught with NURSING 596 CULMINATING PROJECT 6 exacerbation and deteriorations in the children\u00E2\u0080\u0099s quality of life and functioning (Melnyk et al., 2001). Thus creating a state of being characterized by anxiety, fear and disruption related to the spontaneous and often unexpected nature of chronic diseases such as asthma (Melnyk et al., 2001). The Canadian Pediatric Society has recommended the development of a tool or resource which will assist in accurate parental reporting and documentation of symptoms related to asthma (Ducharme et al., 2015). Given this recommendation, the purpose of this manuscript is to assist in the development of a symptom mapping tool (in the form of a diary) that Nurse Practitioners can offer to parents of children under 6 years of age with suspected undiagnosed asthma. In order to create this tool, support from a comprehensive literature review is necessary. This review highlights asthma as a disease, symptomology, how it is diagnosed, treated and how parental perceptions of asthma can impact outcomes. It then goes on to critically analyze various predictive indices currently in use in primary care settings. Next, the review identifies existing diaries and discusses both the merits and downfalls of each; and finally, implications for nurse practitioner practice will be discussed. Methods A comprehensive search was performed on various databases within the University of British Columbia online library. Utilized databases included Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medline, Pubmed, and PsycINFO. The search was limited to English-language articles published between 2000 and 2016. The search was also restricted to include scholarly peer reviewed articles from academic journals. Additional inclusion criteria included qualitative, quantitative, cohort or systematic reviews (including retrospective analyses and nested studies). Chosen articles were those focused on examining pediatric patients with NURSING 596 CULMINATING PROJECT 7 asthma and the clinical process that accompanied the diagnosis. Exclusion criteria included literature reviews, case studies, opinion pieces, editorials, Master\u00E2\u0080\u0099s thesis documents, and dissertations. The search was conducted using the following Boolean operators independently and in combination in an effort to obtain articles which met the inclusion criteria: asthma, asthma diary, asthma diagnosis, asthma in children, asthma management, and parental asthma. The combinations of asthma AND diary yielded 1,142 results in CINAHL and Medline. PsycINFO yielded 21 results when asthma diary was searched. Pubmed yielded a result list of 102 when the keywords \u00E2\u0080\u009Casthma diaries in pediatrics\u00E2\u0080\u009D were utilized. Titles of relevant articles were scanned for relevance. Potential literature was then eliminated if key components were not stated, for example if asthma or pediatric population was not the focus of the article. For example, in the Pubmed result list of 102 publications, articles were excluded based on title, focus, date and study conduction method, resulting in two articles selected for further review. Remaining articles were then assessed by reviewing abstracts and discussions. When reviewing abstracts, particular attention was paid to the purpose, results and outcomes. Discussion sections were reviewed in detail. Altogether, 35 articles originating from the CINAHL, Pubmed, PsychINFO, and Medline were included. Asthma as a disease Asthma is multifactorial, heterogeneous disease characterized by airflow obstruction resulting from the cumulative effects of smooth muscle constriction around airways, airway wall edema, intraluminal mucus accumulation, inflammatory cell infiltration of the submucosa, and basement membrane thickening (GINA, 2015; Sawicki & Haver, 2016). All asthmatic patients have airway inflammation with subsequent altered airway function and symptoms (Panettieri et NURSING 596 CULMINATING PROJECT 8 al., 2008). Furthermore, most (if not all) patients have some form of airway remodeling which worsens over time; however, this is largely evident by 6 years of age (Panettieri et al., 2008). Studies suggest the airway remodeling that occurs in asthma can be present in young children with the disease and appears to be acquired soon after the onset of disease symptoms (Saglani et al., 2007; Spahn & Covar, 2008; Szefler et al., 2014). These airway changes are responsible for the clinical manifestations of cough, wheeze, shortness of breath and chest tightness. Clinically, initial asthmatic response begins immediately after exposure and lasts for up to 2 hours (Brashers, 2010). Allergens bind to mast cells within lung tissue which directly triggers an immune response involving airway smooth muscle constriction (bronchospasm), increased vascular permeability (mucosal edema), and an increase in mucus secretion (Brasher, 2010). Eventually, the late asthmatic response occurs 4 to 8 hours later and can last up to 24 hours post allergen exposure (Brashers, 2010). The immune factors involved in asthma attacks (primarily IgE) contribute either directly to airway inflammation and irritation, or indirectly through the modulation of lung-specific or systemic immune responses (Link, 2014). Risk Factors for Asthma A number of risk factors are cited as contributing to the development of the disease, including variances in genetic phenotypes, presence of atopy or eczema, socioeconomic factors, daycare attendance, viral illnesses, sensitization to allergenic foods such as egg whites and nuts, gastroesophageal reflux, and environmental and in utero exposure to toxins - for example air pollution or tobacco smoke exposure (Amin et al., 2014; Bisgaard & B\u00C3\u00B8nnelykke, 2010; Brashers, 2010; GINA, 2015; Klinner et al., 2001; Link, 2014; Spahn & Covar, 2008). Moreover, older age at first wheezing episode, asthma in one or both parents, eosinophilia, wheezing without colds, and allergic rhinitis are also mentioned in literature as being risk factors NURSING 596 CULMINATING PROJECT 9 (Amin et al., 2014). Klinner et al. (2001) states parental asthma as a risk factor is not limited to the presence of maternal asthma, but those children whose father also had asthma were more likely to have asthma at school age. However, atopy appears to be the strongest and most consistently observed risk factor for the development of asthma (Amin et al, 2014). The association between atopy and the development of asthma derives from the notion of extreme cleanliness in western cultures called the \u00E2\u0080\u009Chygiene hypothesis,\u00E2\u0080\u009D in which lack of early exposure to various airway irritants in very clean households (such as pet dander and dust) favors already sensitized phenotypes and permits induction of asthma (Amin et al., 2014; Brashers, 2010, p. 1331). In fact, primary prevention of asthma through allergen avoidance is generally not recommended in international guidelines as it has a counterintuitive effect (GINA, 2015; Link, 2014; Panettieri et al., 2008). Symptoms and Triggers Wheezing in conjunction with viral infections is the most common presentation of asthma in early life (Link, 2014; Singh, Moore, Gern et al., 2007; Szefler et al., 2014). Suspicion for a diagnosis of asthma in the preschooler include parental report of the child having at least 1 of the following: a tight or clogged chest or throat, difficulty breathing or wheezing which occurs during or after exercise, prolonged exhalation, or wheezing or whistling in the chest in the previous 12 months (Amin et al., 2014; Link, 2014). It is very common for children to experience one or more wheezing episodes before the age of 3 years (Singh et al., 2007). Moreover, there is an inherent difficulty in making the diagnosis of asthma as there is a multitude of other common conditions that can mimic the disease, with presentation patterns often being concurrent (Spahn & Covar, 2008; Szefler et al., 2014). Some studies suggest a link between early respiratory infections and the development of asthma, however, only a minority of NURSING 596 CULMINATING PROJECT 10 children who experienced wheezing with viral respiratory tract infections during the first 3 years of life went on to develop asthma later in childhood (Bisgaard & B\u00C3\u00B8nnelykke, 2010; Link, 2014). Additional studies show less than 50% of children with early-onset wheezing will go on to develop asthma (Bisgaard & B\u00C3\u00B8nnelykke, 2010). Symptoms occurring in the first 3 years of life are often transient, and at school age, 75% of diagnosed asthmatic patients will outgrow asthma by mid-adulthood (Bisgaard & B\u00C3\u00B8nnelykke, 2010). The typical wheezing pattern in healthy infants and preschool aged children consists of short but recurrent exacerbations of cough and wheeze triggered by viral infections but characterized by periods of long, symptom-free intervals (Link, 2014). Studies suggest dividing children into two categories: transient and persistent \u00E2\u0080\u009Cwheezers.\u00E2\u0080\u009D Persistent wheezers were more likely than other children to have mothers with asthma, increased serum IgE levels both in their first year and at age 6 years, and normal lung function in their first year but diminished function at age 6 years (Panettieri et al, 2016). By contrast, the transient wheezers were more likely to have mothers who smoked but not mothers with asthma (Panettieri et al, 2016). Transient wheezers had diminished airway function both before age 1 year and at age 6 years and did not have increased serum IgE levels or skin test reactivity (Panettieri et al, 2016). For those who had wheezed before age 3 years (both persistent and transient early wheezers), poor lung function (assessed by specific airway resistance) at age 3 years predicted the persistence of wheezing at age 5 years (Panettieri et al, 2016). Triggers for asthma are numerous and include tobacco and wood smoke, dust mites, animal dander, cockroach allergens, and indoor mold, with tobacco exposure being cited as the strongest known environmental modifier of the natural history of the disease (Bisgaard & B\u00C3\u00B8nnelykke, 2010; Chui, 2015). Exercise, changes in weather, and emotions can also exacerbate NURSING 596 CULMINATING PROJECT 11 symptoms of the disease (Chui, 2015). Medication use can be a trigger for the development of asthma such as aspirin or beta adrenergic blocking agents, although this is very rare (Chui, 2015; Link, 2014). Furthermore, despite the association of allergies and asthma, researchers suggest perennial and multiple allergies are rare in the first years of life, and this mechanism can only explain a minority of cases of asthma in the population and an even smaller proportion of preschool wheezers (Bisgaard & B\u00C3\u00B8nnelykke, 2010). Therefore, triggers are often individual and variant and thus difficult to pinpoint. Diagnosis Asthma is a syndrome with little consensus and classification of symptoms, which is subject to large variations among patients, physicians, changes in diagnostic traditions over time, as well as with a variable clinical course (Bisgaard & B\u00C3\u00B8nnelykke, 2010). Furthermore, it is difficult to accurately diagnose asthma in children when they experience their first episodes of wheezing as evaluation and treatment algorithms are complex (Bisgaard & B\u00C3\u00B8nnelykke, 2010; Link, 2014). In fact, many physicians are more likely to use the term asthma if a child is known to be allergic, capturing a particular phenotype while potentially excluding others (Bisgaard & B\u00C3\u00B8nnelykke, 2010). Asthma diagnosis should instead be based on reported respiratory symptom patterns and evidence of airway bronchodilator reversibility or airway hyper-responsiveness in response to specific triggers (GINA, 2015; Szefler et al., 2014). Traditionally, asthma diagnosis includes spirometry and peak flow measurements, both of which are considered gold standards. There are three key elements to confirm the diagnosis of asthma: demonstration of variable expiratory airflow limitation, documentation of reversible obstruction, and an exclusion of alternative diagnosis (Amin et al., 2014; Sawicki & Haver, 2016). Due to the inability of children under 6 years to perform - spirometry and peak flow NURSING 596 CULMINATING PROJECT 12 measures, asthma diagnosis in young children is typically based on the reported presence of symptoms and specific risk factors, such as family history and atopy (Huffaker & Phipatanakul, 2014; Sawicki & Haver, 2016; Szefler et al., 2014). The challenges associated with children under 6 years of age being able to perform these tests is attributed to their developmental cognitive stages and their difficulty with following complicated directions associated with spirometry and peak flow tests. Therefore, along with reported symptom patterns from parents, trials of asthma medications (for 2-3 months) such as bronchodilators and inhaled corticosteroids may also help to establish the diagnosis in these children. It is suggested that early initiation of such interventions (asthma medications) will not change the severity and clinical course of the disease (Link, 2014, Szefler et al., 2014; Wilson, Rand, Cabana et al., 2012). Other diagnostic tests to support the diagnosis of asthma include allergy skin testing. Allergy skin testing can be completed in order to establish potential triggers and aeroallergens, however the child must be in an asymptomatic stage (Chui, 2015). A chest radiograph or computed tomography scan may be completed in order to rule out any structural abnormalities or alternative diagnoses (GINA, 2015; Szefler et al., 2014). Biomarker testing is also suggested to confirm diagnosis, however due to the heterogeneity of the disease, biomarker testing has not been conclusively recommended (Bacharier & Guilbert, 2012; Szefler et al., 2014). Finally, exhaled nitric oxide analysis and quantitative analysis of expectorated sputum for eosinophilia are also two novel forms of monitoring asthma and airway inflammation, although they are not recommended by some (Bacharier & Guilbert, 2012; Chui, 2015; Sawicki & Haver, 2016). In summary, due to the limited diagnostic test availability practitioners are limited in their diagnostic resources for children less than 6 years who present with asthma symptoms and therefore must rely heavily on parents for subjective reports of symptom patterns and objective NURSING 596 CULMINATING PROJECT 13 medical examinations (Castro- Rodriguez, 2010). Parental Understanding and Health Literacy As mentioned, diagnosis in children less than 6 years of age is difficult due to limitations in their understanding and ability to follow direction, thus rendering traditional diagnostic modalities for asthma ineffective; the result is a practitioner who must rely solely on parent recollection of episodes in order to trend symptoms over a period of time. It is understood that the younger the child, the less information there is available to clinicians (Link, 2014). To combat difficulties with diagnosis in children within this age group, questionnaires and predictive indices have been suggested by authors, however because these instruments require caregiver assistance for completion, the recorded answers may not reflect the true nature of the underlying disease (Bacharier & Guilbert, 2014; Link, 2014; Szefler et al., 2014). As well, there is an ongoing challenge within pediatric questionnaire development to include developmentally appropriate language and concepts for both child and parent (Szefler et al., 2014). This is especially important when considering the health literacy of parents when reporting episodes, symptoms, treatments and interventions. Inadequate health literacy (HL) limits individuals\u00E2\u0080\u0099 abilities to access and pay for medical care, understand health care advice, weigh the risks and benefits of health decisions, follow recommendations for treatment, use medications correctly and safely, and understand the rights and responsibilities of health care (Shone, Conn, Sanders & Halterman, 2009). Parents with limited HL perceived their child as sicker, had a higher perceived asthma burden, reported poorer interactions with their child\u00E2\u0080\u0099s provider, reported more frequent emergency department use, worried more about their child\u00E2\u0080\u0099s health, and reported lower quality of life than did parents who had adequate HL (Abu- Shaheen, Nofal & Heena, 2016; Shone et al., 2009). Furthermore, low NURSING 596 CULMINATING PROJECT 14 HL has been strongly associated with lower socioeconomic status, lower education level, and other psychosocial factors (Shone et al., 2009). Parents with low levels of education were less able to represent their child\u00E2\u0080\u0099s asthma symptoms in ways providers expected, while parents with low HL were less able to effectively give or receive communications about the child\u00E2\u0080\u0099s asthma and symptoms patterns (Shone et al., 2009; Yoos, Kitsman, Henderson et al., 2007). More importantly, parents who struggle to fill out forms, questionnaires, and documents related to their child\u00E2\u0080\u0099s health were unable to convey important details about their child\u00E2\u0080\u0099s asthma, thus limiting the ability of the clinician to react and respond to episodes that may help lead to an eventual asthma diagnosis (Shone et al., 2009). As previously noted, HL is closely related to disease perception, with parental perceptions and practices being crucial for improving asthma outcomes in children (Abu-Shaheen et al., 2016; Zaraket, Al-Tannir et al., 2011). Unfortunately, several studies suggest many parents prefer not to disclose chronic or recurrent symptoms due to the stigma of asthma. Examples of such stigmas include the perceived inability to participate in certain sports due to the risk of exacerbation, as well as strategic avoidance of environments in an effort to avoid certain allergens and triggers. Parents often assume others will view their child as being chronically ill or in some way disabled when being diagnosed as asthmatic. Furthermore, the majority of parents believed their child had a chest allergy or dyspnea, rather than identifying the episodes as symptoms of asthma (Abe-Shaheen et al., 2016). This failure to disclose for fear of the stigmatization of chronic illness lead to poorer health outcomes and quality of life for children with asthma (Shone et al., 2009). These prevailing misperceptions of asthma are directly responsible for inefficient and inadequate practices taken for asthma control and diagnosis (Abu-Shaheen, 2016). NURSING 596 CULMINATING PROJECT 15 As Canada is a country defined by diverse populations, it is not uncommon for healthcare practitioners to encounter individuals who may have a limited knowledge of such colloquial terms as \u00E2\u0080\u009Cwheeze\u00E2\u0080\u009D. Moreover, as there is an influx of healthcare providers from diverse backgrounds where English is not their primary language, they too may have a limited understanding of the Anglophone word \u00E2\u0080\u009Cwheeze\u00E2\u0080\u009D and thus be reluctant to use the term (Abu-Shaheen et al., 2016). As the presence of \u00E2\u0080\u009Cwheeze\u00E2\u0080\u009D is a defining symptom in the process of diagnosing asthma in a child, the question of HL and understanding presents a dilemma. The practitioner must not only define the disease symptoms such as \u00E2\u0080\u009Cwheeze\u00E2\u0080\u009D but also define the meaning of symptoms related to asthma to both the parent and the child, further calling into question HL in the individual that is reporting and diagnosing symptom patterns. When interpreting the term \u00E2\u0080\u009Cwheeze\u00E2\u0080\u009D there is also a variation in the parental perception and definition of the word, despite primary language spoken. Specifically parents often report no wheeze; however, parents often use other words such as \u00E2\u0080\u009Ccrackly, squeaky, strangled, gasping, rasp, rattle, lisp, animal sounding and air noise\u00E2\u0080\u009D to describe their child\u00E2\u0080\u0099s respiratory symptoms (Callery, 2003, p. 59). Furthermore, some parents used more tangible features such as strangled or gasping; while others referred to the child\u00E2\u0080\u0099s overall appearance, chest movements, and chest vibrations (Callery, 2003). This further demonstrates the variability of perception when reporting asthma symptoms. In summation, early identification of children less than 6 (years of age) who are at greatest risk of developing asthma is a challenge for clinicians due to the complex nature of symptoms patterns, variations of symptoms between individuals, and a lack of reliable diagnostic tests (Panettieri et al., 2008). Objective measures of disease activity are limited and difficult to perform in preschool children due to their developmental cognitive stage (Panettieri et al., 2008). NURSING 596 CULMINATING PROJECT 16 Clinicians must rely heavily on parents and caregivers for information about symptom patterns and treatments. However, health literacy of parents must be considered when completing the complex interview process involved with the diagnosis of asthma in children less than 6. Therefore, for young children with recurrent symptoms suggestive of asthma, the use of a clinical index that incorporates risk elements, such as the Asthma Predictive Index (API) or Prevention and Incidence of Asthma and Mite Allergy (PIAMA) Risk Score might be the best indicator of probable asthma, thus resulting in more appropriate early diagnosis and effective asthma treatment (Panettieri et al., 2008). Review of Clinical Indices As mentioned, two predictive indices have been readily used in asthma care: the API and the PIAMA. Both tools have demonstrated positive effects on asthma outcomes by supporting communication between health care providers and parents (Hafkamp-de Groen et al., 2012). Moreover, the API and PIAMA risk score have been externally validated with results showing their generalizability and thus clinical applicability within various settings (Savenije, Kerkhof, Koppelman et al., 2012). Both of these predictive indices have been developed in an effort to prevent the inadequate treatment of childhood asthma in patients who potentially could be lost to follow-up by primary and secondary health care (Hafkamp-de Groen, Lingsma, Caudri et al., 2012). Despite the use of various predictive models which have been proposed to diagnose asthma, there are also complex and invasive tests or exams to aid in diagnosis. However, researchers suggest utilizing prediction tools such as bloodwork or bronchoalveolar lavage are not feasible given the low acceptance of drawing blood in various settings by both parents and children or potential for trauma related to these invasive procedures; as well as an identifiable lack of funding for laboratory tests which are focused on preventative healthcare within this NURSING 596 CULMINATING PROJECT 17 population (Castro-Rodriguez, 2010; Hafkamp-de Groen et al., 2012). Furthermore, specific serum biomarkers that have been linked to the development of asthma (such as IgE) have been shown to be affected by age and therefore are difficult to interpret in young children (Huffaker & Phipatanakul, 2014). Literature goes on to state that it is important to create relevant primary care driven predictive indices in order to capture children who begin to show asthma symptoms at a time when they regularly visit clinics for well-child care within the community setting (Fouzas & Brand, 2013; Hafkamp-de Groen et al., 2012; Hafkamp-de Groen et al., 2013). Moreover, there is an identified need for an asthma predictive index appraisal tool that supports health care professionals, specifically novice providers, in their decision making when a preschool aged child presents with asthma symptoms to their clinic as diagnosis is clearly complicated and challenging (Hafkamp-de Groen et al., 2012). API Analysis The API was developed by Castro-Rodriguez in 2000 in an effort to identify children who may develop asthma, and was created using data from 1,246 children in the Tucson Children\u00E2\u0080\u0099s Respiratory Study birth cohort (Castro-Rodriguez, 2010). The development of asthma in this predictive index is based on several factors found during the first 3 years of life and includes 1 of 2 major criteria (physician diagnosed eczema or parental asthma), or 2-3 minor criteria (physician diagnosis of allergic rhinitis, wheezing without colds, or peripheral eosinophilia >4% (Castro-Rodriguez, 2010; Castro-Rodriguez, 2013). Overall, the API is well validated and internationally supported although many clinicians remain skeptical about its utility in various settings (Huffaker & Phipatanakul, 2014). The stringent API is a simpler and less expensive tool than other more invasive modalities to identify children less than 6 years of NURSING 596 CULMINATING PROJECT 18 age who are at risk for developing asthma, and has exclusively been proven effective for use in younger children (<6 years of age) rather than older children (>6 years of age) (Castro-Rodriguez, 2010; Huffaker & Phipatanakul, 2014). Among the various predictive indices, the API is the only one which has been tested in different populations and in independent studies such as randomized clinical trials (Castro-Rodriguez, 2010). As a result, the API has the best combination of sensitivity, specificity, and predictive value of the indices and increases the probability of prediction of asthma by up to 4 times (Casto-Rodriguez, 2010; Castro-Rodriguez, 2013). Finally, this predicative index is multifunctional in that the features used to define a positive API score may also be successfully implemented into clinical practice by not only predicting disease development but also allowing practitioners to predict response to therapeutic treatment (Castro-Rodriguez, 2010; Hafkamp-de Groen et al., 2012). PIAMA Analysis The PIAMA Risk Score has been proposed as an instrument which predicts asthma at age 7\u00E2\u0080\u00938 years of age, using easily obtainable parameters and is assessed at the time of initial presentation of asthma-like symptoms (Hafkamp-de Groen et al., 2012). The PIAMA Risk Score discriminates between asthmatic and non-asthmatic children, and may be a suitable tool for use in well-child visits within community health settings (Caudri, 2009). The Risk Score includes parameters, and much like the API, is preferred above other prediction models such as blood tests, due to its less invasive and intrusive nature (Hafkamp-de Groen et al., 2012). The PIAMA Risk Score has 8 predictors: male sex, post-term delivery, parental education, parental inhalation medications (such as puffers), wheezing/dyspnea apart from colds, wheezing frequency, respiratory tract infections, and physician\u00E2\u0080\u0099s diagnosis of eczema (lifetime) and/or present eczematous rash (Hafkamp-de Groen et al., 2012; Hafkamp-de Groen et al., 2013; Castro-NURSING 596 CULMINATING PROJECT 19 Rodriguez, 2013). It utilizes a combination of parental report of symptom patterns, medical examinations, and health care records to assess each variable. It is the first study that reported post-term delivery as an independent predictor in any studied asthma prediction model (Hafkamp-de Groen et al., 2013). The discriminative ability of the PIAMA Risk Score is similar at different ages and in various ethnic and socioeconomic subgroups of preschool children which suggests good generalizability (Hafkamp-de Groen et al., 2013). Although the PIAMA risk score has good external validity, some studies call for the score to be reproduced in other populations and settings in order to assess its clinical relevance (Hafkamp-de Groen et al., 2013). Criticisms of the PIAMA Risk Score indicate that the predicted risks by the original Risk Score for having asthma at the age of 6 years were systematically overestimated (Hafkamp-de Groen et al., 2013). Compared to other predictive indices, the PIAMA index uses a more complicated approach, with odds ratios for individual predictors (Hafkamp-de Groen et al., 2013). Overall, the PIAMA system generates a more accurate predictive model, but the score is somewhat laborious to determine because the different factors involved have different weighted significance (Castro-Rodriguez, 2010). Moreover, the score relies heavily on accurate parental report of both personal and child health statuses at specific times, for example, wheezing frequency and use of parental inhaled medications at any point (Hafkamp-de Groen et al., 2013). Considering asthma is a complex disorder that is highly individual as well as multi-factorial, authors have suggested additional factors to consider which were otherwise omitted from the first risk model (Hafkamp-de Groen et al., 2012). These include: child\u00E2\u0080\u0099s ethnicity, preterm birth, sleeping problems due to asthma symptoms, physician visits due to asthma symptoms, wheezing patterns, allergy or general health (Hafkamp-de Groen et al., 2012). By identifying additional factors, authors highlight the complex nature of the disorder and identify that although there are NURSING 596 CULMINATING PROJECT 20 many common congruencies to the development of the illness, it is not always completely predictable. In summary, clinicians, particularly novice care providers, require modalities that simplify and streamline diagnosis yet they are wary of predictive indices for complex diseases which have not been validated in different settings, particularly in their own (Castro-Rodriguez, 2010). Practitioners must therefore instinctively use multiple parameters to make management decisions based on their own training and personal experience (Castro- Rodriguez, 2010). Before they begin using a predictive index, they need to be convinced by evidence based literature that it will ultimately improve the care of their patients. More specifically, even if an index is accurate, it must be easy to apply, validated in different populations and shown to improve patient outcomes in order to be used by busy clinicians (Castro- Rodriguez, 2010). Asthma Diaries It is well established predicting asthma is a complex and complicated process that involves many factors. In order to bridge the gap between parental report and accurate symptom portrayal, primary care practitioners can utilize symptom recording methods, such as diaries or questionnaires, to assist with diagnosis and appropriate treatment modalities. Current literature describes the use of diaries in many chronic diseases, specifically asthma and COPD. However, most diaries or journals are utilized and studied in individuals who have already been diagnosed and are currently receiving treatment and thus managing the knowledge, fears and feelings that are associated with their illness. In chronic disease management, it is important to regularly monitor disease status in an effort to capture disease burden on both the patient and caregivers (Cruz-Correia, Fonseca, Lima et al., 2007). Therefore, asthma diaries are useful for gathering clinical information ultimately resulting in the more effective care of patients, helps guide self-NURSING 596 CULMINATING PROJECT 21 management through symptom monitoring, better medication adherence, improves assessment and hones patient-provider communication (Cruz-Correia et al., 2007; Rhee, Fairbanks & Butz, 2014). When considering a potential asthma diagnosis, many studies rely on the use of questionnaires for answers regarding symptom patterns and treatments. Although standard respiratory questionnaires have shown good or satisfactory repeatability, they may not be appropriate for use with infants and preschool children where symptoms may differ due to developmental changes and where reports rely exclusively on proxy parents (Strippoli, Silverman, Michel & Kuehni, 2007). Many of these tools assume the asthma diagnosis is firmly established and caregivers are familiar with treatment approaches. Therefore, most asthma questionnaires are appropriate for use in the management process as most are focused on the global concept of asthma, which incorporates both current symptoms and risk of future attacks (Szefler et al., 2014; Wilson, Rand, Cabana et al., 2012). Furthermore, questionnaires completed by individuals in office have downfalls, one of which is long and often inaccurate recall duration as well as the integration of questions that often fail to capture the effect of the disease on things like sleep and daily activities, both of which are key indicators of symptom severity in asthma (Globe, Martin, Schatz et al., 2015; Voorend-van Bergen, Vaessen-Verberne, Landstra et al., 2014). Questionnaires require caregiver participation for completion, thus the recorded answers may not reflect the true nature of the underlying disease but rather an interpretation of it by their children and others around them (Szefler et al., 2014). Therefore, when choosing assessment methods that assist in predicting or treating chronic illnesses, it is important to utilize the most appropriate measure for the patient and illness in question. NURSING 596 CULMINATING PROJECT 22 Appropriateness of Diaries for Asthma Diaries are self-reported instruments used repeatedly to examine ongoing experiences, and offer practitioners the opportunity to investigate social, psychological, and physiological processes within everyday situations (Bolger, Davis & Rafaeli, 2003). The benefit of using the diary method is that they permit the examination of reported events and experiences in their natural, spontaneous context, and provide further information which is complementary to the patient perspectives traditionally being provided by means such as questionnaires and interviews (Bolger et al., 2003). Diaries have the advantages of being prospective and less reliant on parental memory, which is often skewed in the moment (Lam, Barr, Catherine et al., 2010). One of the greatest strengths of diary designs is they are excellent for studying temporal dynamics, specifically episodes or phenomena that occur unexpectedly and without provocation (Bolger et al., 2003). As well, with repeated exposure to diary questions and topics, participants\u00E2\u0080\u0099 understanding of a particular illness changes in several ways: they develop a more complex or enhanced understanding of the concept in question and the self-reflective recollection process becomes therapeutic in nature (Bolger et al., 2003). For chronic disease management such as asthma, patients are encouraged to actively participate in their care and treatment and to self-manage their health and illness (Kruijssen et al., 2015). The use of self-management diaries helps to improve individuals\u00E2\u0080\u0099 insight into their disease and subsequently increases empowerment and control over their illness (Kruijssen et al., 2015). From a patient perspective, self-management also acts as a way to gain more knowledge and insight into one\u00E2\u0080\u0099s disease but also as a means to utilize that insight to cope more effectively with the disease by recognizing an exacerbation and acting on it (Kruijssen et al., 2015). As a result, self-management approaches improve patients\u00E2\u0080\u0099 knowledge of their disease, treatment, and NURSING 596 CULMINATING PROJECT 23 increases their motivation and confidence that the disease can be controlled, thereby improving treatment adherence and symptom management (Kruijssen et al., 2015). This control can be best exemplified by the creation of an effective and open patient provider relationship early on in the treatment and diagnosis stage (In\u00E2\u0080\u0099t Veen, Mennema & Noort, 2012; Kruijssen et al., 2015). Though starting self-management diaries may require more time with patients, ultimately, it results in patients who have improved insight into their health, cope better with their chronic illness, participate and comply with treatment options and report an improved quality of life (Rhee, Fairbanks & Butz, 2014). As nurse practitioners and primary care providers, it is important to acknowledge, understand, and identify symptoms suggestive of asthma that may deviate beyond just coughing and wheezing (Rhee, Fairbanks & Butz, 2014). As traditional questionnaires can ultimately allow for flawed recall on the part of a stressed, overwhelmed or scared parent, it is incumbent upon us to create tools allowing for open and accurate portrayal of symptoms and to decrease reporter burden. By creating My Breathing Buddy, an event contingent tool requiring participants to provide a self-reported notation each time an event in question occurs, we enable the assessment of individual episodes which would not necessarily be captured by fixed or random interval assessments such as questionnaires; thus empowering patients and parents alike. Design of My Breathing Buddy Although design aspects of journals and diaries were not frequently highlighted within the literature, salient points were recommended by a qualitative study focused on adolescent use of diaries and their perception of asthma exacerbations and management. One such suggestion was it is important to include questions that highlight activity limitations that are a direct consequence of debilitating symptoms related to asthma (Rhee et al., 2014). Open-ended NURSING 596 CULMINATING PROJECT 24 questions that were not too direct allowed for optimal recollection and freedom of interpretation (Rhee et al., 2014). Furthermore, the integration of pointed questions limited the ability of participants to recall results in retrospective aggregate responses that potentially could reflect a faulty representation of an illness or phenomena of interest (Bolger et al., 2003). Diaries or journals must also allow for short entries which take several minutes to complete and thus encourage prompt participation (Rhee et al., 2014). The design of the diary must have ample free writing space that minimizes limitations and allows for freedom of responses (Bolger et al., 2003). This allows for recognition of temporal patterns and ability to acknowledge unconventional associations between symptoms and triggers (Bolger et al., 2003). Language within a diary should be kept simple and understandable in an effort to avoid confusions and decrease the potential for reporter burden associated with completing the task. This becomes especially important when being used in stressful situations such as an emergency department visit where actions are taken quickly and multiple providers are involved in care. Lastly, the integration of a space where care providers can complete information about interventions and diagnoses should be included to avoid unintentional omissions in recall by parents or caregivers. Limitations to Diary Use There are several limitations that exist when considering the use of diaries. One such limitation of paper diaries includes participants forgetting to complete diary entries, and thus provider uncertainties regarding compliance and retrospection errors; this is also referred to as backfilling of a journal over a period of time (Lam et al., 2010). Retrospective error is further defined as the moment when participants rely on a reconstruction or fabrication to complete missed entries, thus potentially defeating the main benefit of diaries, namely their ability to NURSING 596 CULMINATING PROJECT 25 obtain accurate information (Bolger et al., 2003). An example of this would be participants completing the diary minutes before a medical appointment in an effort to avoid being reprimanded for noncompliance. Another important potential constraint is the burden of recording that is placed on the participant (Bolger et al., 2003). A contributing factor to this is the requested frequency, detail, and duration of recording, and the requested context in which the recordings are made (Lam et al., 2010). That is, the more specific and detailed the entries must be, the more burden that is placed on the parent or participant. However, unexpectedly there was a discrepancy identified by Strippoli et al. (2007) between fathers who reported symptoms versus mothers who reported symptoms to providers. Specifically, when fathers responded, significantly lower repeatability of results was found for questions centered around current symptoms of asthma and infant care. Authors attributed this to mothers generally being the primary caregivers at home on a daily basis whereas fathers generally take time off work and are present when children are ill and are otherwise not actively participate in the daily home activities and care (Strippoli et al., 2007). The result of the more consistent presence of mothers is that, generally, there is a more accurate portrayal of the child\u00E2\u0080\u0099s daily health status in regards to exacerbations and triggers of asthma (Strippoli et al., 2007). In an effort to avoid the inevitable difficulties associated with remembering to use the tool as well as the potential for losing the diary, many studies suggested the integration of e-diaries rather than paper diaries. Diaries require commitment and dedication for their completion on the part of both patient and provider in that detailed instructions and explanations must be provided prior to use, as well as continual support on the part of the practitioner in the event the diary is lost or questions arise. By supporting the parent and patient, nurse practitioners can develop a healthy and open therapeutic relationship in regards to potential NURSING 596 CULMINATING PROJECT 26 asthma symptoms, treatment, diagnosis and management that potentially combats or reduces caregiver burnout and ineffective coping. Implications for Practice Supporting parents and clients through the anxiety inducing process of discovering a potentially life changing chronic illness should always be a Nurse Practitioner\u00E2\u0080\u0099s foremost priority. Nurse Practitioners must understand early recognition and treatment of symptoms closely resembling asthma will dramatically impact the patient and family in a positive way. As well, a collaborative and trusting relationship between family and practitioner must be established in order to successfully manage the potential disease in the long term (Link, 2014). Parents of children who have been diagnosed with asthma often identify there is a disconnect in communication between practitioners and parents. Often, the two groups disagree in the amount of time dedicated to asthma education in the office with conversations surrounding medication side effects and treatments often being neglected; furthermore, practitioners often overestimate the extent of knowledge parents already possess regarding the illness itself, potentially limiting the amount of teaching being done because of assumptions surrounding existing parental knowledge (Wendling, 2006; Yoo et al., 2007). The result of these discrepancies in education on the part of parents and practitioners is poor asthma treatment compliance, more frequent symptoms, and a greater use of Emergency Departments (Wendling, 2006). Therefore, asthma education should begin early, specifically before the diagnosis is made. Parents are often overwhelmed by the potential diagnosis and their capacity for absorption of education is limited during this time; capturing the moment to learn is imperative. Education for parents and patients should be supportive and holistic. Both stakeholders should have the opportunity to express their perspectives and concerns about their potential NURSING 596 CULMINATING PROJECT 27 diagnoses freely. Parents and patients need to be introduced early on to the language surrounding asthma, such as bronchodilators, inhalers, triggers and wheeze in order to increase understanding, awareness and empowerment. Link (2014) identifies asthma care can only be successful if long term relationships are established among patient, parent and asthma care team. By integrating an autonomous diary into therapeutic relationships, where parents can take control of their child\u00E2\u0080\u0099s care and documentation, communication becomes opened and improved. Frequent follow up should be encouraged which integrates concerns from both the parent and patient and discusses in detail the results that are recorded in the diary. Discussions should be tailored to the individual needs of the patient based on risk, impairment, and need for additional counselling and education (Link, 2014). Health literacy should be addressed by the Nurse Practitioner in the early stages of disease presentation. Reasons for this are to enhance understanding and competence around illness and health care navigation and to identify barriers to appropriate care, for example clearly defining what is a wheeze or reinforcing the correct usage of primary and tertiary health care centers. By using a diary called My Breathing Buddy, cultural perceptions of the disease can be established in the early stages of diagnosis by addressing beliefs surrounding the meaning of the word wheeze and the stigma attached to illness presentation. This tool promotes and encourages open dialogue between care providers, patients, and families that will ultimately end in optimal outcomes for the patients. This tool also presents a vehicle for practitioners to introduce frequently used terms related to asthma to parents and patients, as well as begin a conversation around what traditionally accompanies a diagnosis of asthma, such as various tests and treatments. By doing so, the Nurse Practitioner can assist families in the detection and response to fluctuations in breathing which eventually allows parents to act with confidence and assurance in the care of their asthmatic child. This NURSING 596 CULMINATING PROJECT 28 empowerment therefore establishes an interactive partnership between patient, parent and provider which is collaborative, holistic and supportive (Link, 2014). Creation of My Breathing Buddy As mentioned, My Breathing Buddy is a tool which functions as a travelling record or chart. The development of such a tool takes into account usability and applicability for both parent and patient; therefore, this tool must be appropriate for both target users. To start, the brightly colored cover will be inviting, as well as easily recognizable in times when a parent may be prone to forgetting such tools, for example in a stressful moment where the parent is quickly leaving the household to go to a clinic or an emergency department. The title page will be arranged in such a way that graphics on the front cover are pleasant and non-cluttered. The inside page will include a small description about the tool and how to properly use it, followed by a page that includes the child\u00E2\u0080\u0099s demographic information including name, home telephone number, date of birth and gender at birth as well as a notation that, if found, the tool can be returned to a specific location, be it the home or clinic. Nurse Practitioners who are dispensing this tool must ensure parents are informed of the potential for breach of confidentiality if lost; therefore, it is up to parents to disclose as much or as little personal information as they feel comfortable recording within the demographics page. The next page will include birth history, including: gestational age, birth weight, complications during the pregnancy, vaginal or cesarean birth, hospitalizations after birth, previous medical history, breast feeding history and known allergies. The next page will include family medical history such as mother, father or sibling(s) and their medical conditions. Conditions specifically highlighted are ones linked with atopy such as eczema (diagnosed by a healthcare practitioner) or asthma (persistent and/or childhood), as well as use of inhaler medications and presence of hay fever. This page will also highlight the NURSING 596 CULMINATING PROJECT 29 environment in which the child lives, paying close attention to exposure cigarette smoke, daycare attendance, pet avoidance and current family pets. In order to encourage participation of the child in the history portion of the diary, there will be a consistent presence of a mascot throughout the tool. The mascot's name is \u00E2\u0080\u009CBuddy the Diagnosis Detective\u00E2\u0080\u009D and is in the form of a friendly dog that will encourage children to participate in the use of the diary. The name \u00E2\u0080\u009CBuddy\u00E2\u0080\u009D is strategic as it is not gender specific and implies the tool is friendly and non-intimidating. The diary or tool will then lead into separate sections identified by colorful dividers labeled as: home, clinic and hospital. Dividing the symptom diary component, will allow for quick identification by both parent and practitioner during the recording and interviewing processes. Also, each section will be punctuated with large-scale graphics that can be used as a coloring book for the child when waiting to see a physician or Nurse Practitioner; thus providing a multipurpose component. By creating an interactive tool for both parents and children, the aim is to incentivize the use of the diary. Within each section, there will be simple lead-in phrases (such as, \u00E2\u0080\u009CToday, my child had a cough \u00E2\u0080\u00A6\u00E2\u0080\u009D) alluding to the symptoms of asthma, followed by large blank spaces intended to give parents the opportunity to fill in more information they deem as relevant and important. Within the clinic section of the diary, each page is dedicated to one singular visit. When a parent brings their child to the primary care practitioner for respiratory symptoms, prior to meeting the practitioner they will have completed the clinic pages either at home or in the waiting room. This information will include the date, time and specifics regarding the development of symptoms and signs that compelled them to seek help; specifically: when did the symptoms start; was there any wheezing that the parent could hear; was there rhinorrhea, cough, disturbed sleeping, or rash? In these sections, there will be an NURSING 596 CULMINATING PROJECT 30 abundance of free space to allow for parents to further expand on any symptoms that were omitted in the lead-in phrases. There will be a section labeled Treatment on the same page, which would be completed either before visiting the clinic or during, that explains any medical treatments the child has undergone; for example: nebulizers or puffers. Finally, each entry will finish with a section that the primary care provider completes. This portion of the page will be called Care Provider Impression in which a working diagnosis is recorded and there will be a sub-section for completion which states \u00E2\u0080\u009Cwheeze present\u00E2\u0080\u009D or \u00E2\u0080\u009Cwheeze absent\u00E2\u0080\u009D and can easily be circled by the Nurse Practitioner or physician. All language used in this tool will be simple and easy to understand. Each section will be similar in its format so as not to confuse the reader and the participant, thus preventing inappropriate or inaccurate use of the diary. Each section will contain multiple episode pages that allow for ample recording room. At the end of the diary, there will be large lined pages labeled \u00E2\u0080\u009CNotes\u00E2\u0080\u009D where parents can record questions, concerns or symptom outliers they may have noted. Despite the uncomplicated form and function of this tool, its use could potentially be daunting and intimidating to the novice parent. In order to create a therapeutic and supportive environment to families that may be experiencing new challenges, the Nurse Practitioner must foster an environment of trust and understanding. In order to do this, it is important the Nurse Practitioner explain each page in detail when dispensing this tool. The Nurse Practitioner must emphasize this tool is meant to assist in the diagnosis but will not be the sole piece of diagnostic evidence. Parents must be reassured that this tool is meant to lift the burden of recollection from the parent and child and to help support them through a difficult and potentially life-changing experience. NURSING 596 CULMINATING PROJECT 31 Conclusion In summary, asthma is a complex reversible obstructive airway disease involving many variable symptoms and triggers. The presence of multiple risk factors such as genetics, the presence of atopy as well as early symptoms of wheeze can help predict illness development. Diagnosis of asthma is made using several modalities including spirometry and peak flow, both of which cannot be reliably completed in children less than 6 years old. Various predictive indices have been identified to help streamline diagnoses and thus avoid airway remodeling and improve overall lung function. However, some of these indices are not appropriate as health literacy and disease understanding varies among many individuals and thus impacts the reporting patterns of symptoms. Nurse Practitioners can support this process by utilizing tools such as diaries and journals that chronical symptom patterns and treatments received in various setting in order to support parents and patients as well as appropriately diagnose individuals in a timely manner. By creating a diary entitled My Breathing Buddy, Nurse Practitioners, can introduce parents and patients to asthma in a more holistic approach, and eventually empower parents to take control of their child\u00E2\u0080\u0099s health in a more comprehensive manner. NURSING 596 CULMINATING PROJECT 32 References Abu-Shaheen, A. K., Nofal, A., & Heena, H. (2016). Parental Perceptions and Practices toward Childhood Asthma. Biomed Research International, 1-7. doi:10.1155/2016/6364194. Akinbami LJ, Sullivan SD, Campbell JD, Grundmeier RW, Hartert TV, Lee TA, et al. (2012). Asthma outcomes: Healthcare utilization and costs. The Journal Of Allergy And Clinical Immunology.129(Suppl):S49-64. \u00E2\u0080\u00A8 Amin, P., Levin, L., Epstein, T., Ryan, P., LeMasters, G., Khurana Hershey, G., . . . Bernstein, D. I. (2014). Optimum predictors of childhood asthma: Persistent wheeze or the asthma predictive index? The Journal of Allergy and Clinical Immunology. in Practice, 2(6), 709-715.e2. doi:10.1016/j.jaip.2014.08.009. Bacharier L.B., Guilbert T.W. (2012). Diagnosis and management of early asthma in preschool- aged children. The Journal of Allergy and Clinical Immunology. 130:287-98. Bisgaard, H., & B\u00C3\u00B8nnelykke, K. (2010). Long-term studies of the natural history of asthma in childhood. Journal of Allergy and Clinical Immunology, 126(2), 187-197. doi:10.1016/j.jaci.2010.07.011. Bolger, N., Davis, A., & Rafaeli, E. (2003). Diary methods: Capturing life as it is lived. Annual Review of Psychology, 54(1), 579-616. doi:10.1146/annurev.psych.54.101601.145030. Brashers, V.L. in McCance, K. L., & Huether, S. E. (2010). Pathophysiology: The Biologic Basis for Disease in Adults and Children (6th ed.). Maryland Heights, MO: Mosby Elsevier. Brunekreef, B., Smit, J., de Jongste, J., Neijens, H., Gerritsen, J., Postma, D., . . . van Strien, R. (2002). The prevention and incidence of asthma and mite allergy (PIAMA) birth cohort study: Design and first results. Pediatric Allergy and Immunology, 13(s15), 55-60. doi:10.1034/j.1399-3038.13.s.15.1.x. NURSING 596 CULMINATING PROJECT 33 Callery, P. (2003). Parents' accounts of their children's respiratory symptoms showed a range of interpretations. Evidence Based Nursing, 6(2), 59. Castro-Rodriguez J.A., Holberg C.J., Wright A.L., Martinez, F.D. (2000). A clinical index to define risk of asthma in young children with recurrent wheezing. American Journal of Respiratory and Critical Care Medicine, 162:1403-6. \u00E2\u0080\u00A8 Castro-Rodriguez, J. (2010). The asthma predictive index: A very useful tool for predicting asthma in young children. Journal of Allergy and Clinical Immunology, 126(2), 212- 216. doi:10.1016/j.jaci.2010.06.032. Castro-Rodriguez, J. A. (2013). The necessity of having asthma predictive scores in children. Journal of Allergy and Clinical Immunology, 132(6), 1311-1313. doi:10.1016/j.jaci.2013.09.006. Caudri, D. (2009). Predicting the long-term prognosis of children with symptoms suggestive of asthma at preschool age. Journal of Allergy and Clinical Immunology, 124(5), 903- 910.e7. doi:10.1016/j.jaci.2009.06.045. Caudri, D., Wijga, A., A Schipper, C. M., Hoekstra, M., Postma, D. S., Koppelman, G. H., & ... de Jongste, J. C. (2009). Predicting the long-term prognosis of children with symptoms suggestive of asthma at preschool age. Journal Of Allergy And Clinical Immunology, 124(5), 903-10.e1-7. doi:10.1016/j.jaci.2009.06.045. Chui, A.M. in Marcdante, K. M., & Kliegman, R. M. (2015). Nelson Essentials of Paediatrics (7th ed., pp. 273-282). Philideplphia, PA: Elsevier Saunders. Cruz-Correia, R., Fonseca, J., Lima, L., Araujo, L., Delgado, L., Castel- Branco, M. G., & Costa- Pereira, A. (2007). Web-based or paper-based self-management tools for asthma- NURSING 596 CULMINATING PROJECT 34 Patients' opinions and quality of data in a randomized crossover study. Studies in Health Technology and Informatics, 127, 178\u00E2\u0080\u0093189. Diaz-Vazquez C, Torregrosa-Bertet MJ, Carvajal-Uruena I, Cano-Garcinuno A, Fos-Escriva E, Garcia-Gallego A, et al. (2009). Accuracy of ImmunoCAP Rapid in the diagnosis of allergic sensitization in children between 1 and 14 years with recurrent wheezing: the IReNE study. Journal of Pediatric Allergy Immunology. 20:601-9. Ducharme, F. M., Dell, S. D., Radhakrishnan, D., Grad, R. M., Watson, W. T., Yang, C. L., & Zelman, M. (2015, October). Diagnosis and management of asthma in preschoolers: A Canadian Thoracic Society and Canadian Paediatric Society position paper. In Canadian Paediatric Society. Retrieved September 28, 2016, from http://www.cps.ca/en/documents/position/asthma-in-preschoolers#ref5. Global Initiative for Asthma (GINA) (2015). Pocket Guide for Asthma Management and Prevention: For Children 5 Years and Younger. Retrieved from http://ginasthma.org/pocket-guide-for-asthma-management-and-prevention-in-children-5- years-and-younger/ on January 11, 2017. Globe, G., Martin, M., Schatz, M., Wiklund, I., Lin, J., von Maltzahn, R., & Mattera, M. S. (2015). Symptoms and markers of symptom severity in asthma--content validity of the asthma symptom diary. Health and Quality of Life Outcomes, 13(1), 21-21. doi:10.1186/s12955-015-0217-5. Fouzas, S., & Brand, P. (2013). Predicting persistence of asthma in preschool wheezers: crystal balls or muddy waters? Paediatric Respiratory Reviews, 14(1), 46-52. doi:10.1016/j.prrv.2012.08.004. NURSING 596 CULMINATING PROJECT 35 Hafkamp-de Groen, E., Lingsma, H. F., Caudri, D., Wijga, A., Jaddoe, V. W., Steyerberg, E. W., & ... Raat, H. (2012). Predicting asthma in preschool children with asthma symptoms: study rationale and design. BMC Pulmonary Medicine, 12(1), 65. doi:10.1186/1471- 2466-12-65. Hafkamp-de Groen, E., Lingsma, H. F., Caui, D., Levie, D., Wijga, A., Koppelman, G. H., . . . Raat, H. (2013). Predicting asthma in preschool children with asthma-like symptoms: Validating and updating the PIAMA risk score. Journal of Allergy and Clinical Immunology, 132(6), 1303-+. doi:10.1016/j.jaci.2013.07.007. Huffaker, M. F., & Phipatanakul, W. (2014). Utility of the Asthma Predictive Index in predicting childhood asthma and identifying disease-modifying interventions. Annals of Allergy, Asthma & Immunology, 112(3), 188-190. doi:10.1016/j.anai.2013.12.00.1. In\u00E2\u0080\u0099t Veen J, Mennema B., & Van Noort E. (2012) Online self-management in COPD or asthma: with or without the healthcare provider? European Respiratory Journal, 40(Suppl 56):P1284.\u00E2\u0080\u00A8 Klinner, M. D., Nelson, H. S., Price, M. R., Adinoff, A. D., Leung, D. Y. M., & Mrazek, D. A. (2001). Onset and persistence of childhood asthma: Predictors from infancy. Pediatrics, 108(4), e69-e69. doi:10.1542/peds.108.4.e69. Kruijssen, V. V., Staa, A. V., Dwarswaard, J., Mennema, B., Adams, S. A., & Veen, J. (2015). Use of Online Self-Management Diaries in Asthma and COPD: A Qualitative Study of Subjects' and Professionals' Perceptions and Behaviors. Respiratory Care, 60(8), 1146- 1156. doi:10.4187/respcare.03795. Lam, J., Barr, R. G., Catherine, N., Tsui, H., Hahnhaussen, C. L., Pauwels, J., & Brant, R. (2010). Electronic and paper diary recording of infant and caregiver behaviors. Journal of NURSING 596 CULMINATING PROJECT 36 Developmental and Behavioral Pediatrics: JDBP, 31(9), 685. doi:10.1097/DBP.0b013e3181e416ae. Link, H. W. (2014). Pediatric asthma in a nutshell. Pediatrics in Review, 35(7), 287-298. doi:10.1542/pir.35-7-287. Looijmans-van den Akker, I., van Luijn, K., & Verheij, T. (2016). Overdiagnosis of asthma in children in primary care: a retrospective analysis. British Journal of General Practice, 66(644), e152-e157. doi:10.3399/bjgp16X683965. Melnyk, B., Feinstein, N., Moldenhouer, Z., & Small, L. (2001). Coping in parents of children who are chronically ill: strategies for assessment and intervention. Pediatric Nursing, 27(6), 548-573. Panettieri, R. J., Covar, R., Grant, E., Hillyer, E. V., & Bacharier, L. (2008). Natural history of asthma: persistence versus progression-does the beginning predict the end?. The Journal Of Allergy And Clinical Immunology, 121(3), 607-613. doi:10.1016/j.jaci.2008.01.006. Revicki, D., & Weiss, K. B. (2006). Clinical assessment of asthma symptom control: Review of current assessment instruments. Journal of Asthma, 43(7), 481-487. doi:10.1080/02770900600619618. Saglani S, Payne DN, Zhu J, Wang Z, Nicholson AG, Bush A, et al. (2007). Early detection of airway wall remodeling and eosinophilic inflammation in preschool wheezers. American Journal of Respiratory and Critical Care Medicine. 176:858-64. Savenije, O. M., Kerkhof, M., Koppelman, G. H., & Postma, D. S. (2012). Predicting who will have asthma at school age among preschool children. Journal of Allergy and Clinical Immunology, 130(2), 325-331. doi:10.1016/j.jaci.2012.05.007. NURSING 596 CULMINATING PROJECT 37 Sawicki, G. & Haver, K. (2016). Asthma in children younger than 12 years: Epidemiology and pathophysiology. UpToDate. Retrieved from https://www.uptodate.com/contents/asthma- in-children-younger-than-12-years-epidemiology-and-pathophysiology?source=see_link on January 11, 2017. Shone, L. P., Conn, K. M., Sanders, L., & Halterman, J. S. (2009). The role of parent health literacy among urban children with persistent asthma. Patient Education and Counseling, 75(3), 368-375. doi:10.1016/j.pec.2009.01.004. Singh A.M., Moore P.E., Gern J.E., Lemanske R.F. Jr, Hartert T.V. (2007). Bronchiolitis to asthma: a review and call for studies of gene-virus interactions in asthma causation. Am J Respir Crit Care Med. 175:108-19. Spahn, J. D., & Covar, R. (2008). Clinical assessment of asthma progression in children and adults. Journal of Allergy and Clinical Immunology, 121(3), 548-557. doi:10.1016/j.jaci.2008.01.012. Szefler, S. J., Chmiel, J. F., Fitzpatrick, A. M., Giacoia, G., Green, T. P., Jackson, D. J., & ... Raissy, H. H. (2014). Asthma across the ages: knowledge gaps in childhood asthma. Journal of Allergy and Clinical Immunology, 133(1), 3-13. doi:10.1016/j.jaci.2013.10.018. Voorend-van Bergen, S., Vaessen-Verberne, A. A., Landstra, A. M., Brackel, H. J., van den Berg, N. J., Caudri, D., & ... Pijnenburg, M. W. (2014). Monitoring childhood asthma: web-based diaries and the asthma control test. Journal of Allergy and Clinical Immunology, 133(6), 1599-605.e2. doi:10.1016/j.jaci.2013.10.005. NURSING 596 CULMINATING PROJECT 38 Wendling, P. (2006). Asthma Survey Reveals Communication Gaps Between Physicians and Parents. Clinical Psychiatry News. Retrieved from http://bit.ly/2iCboja on January 22, 2017. Wilson S.R., Rand C.S., Cabana M.D., Foggs M.B., Halterman J.S., Olson L., et al. (2012). Asthma outcomes: quality of life. Journal of Allergy and Clinical Immunology. 129(Suppl): S88-123. Yoos, H. L., Kitzman, H., Henderson, C., McMullen, A., Sidora-Arcoleo, K., Halterman, J. S., & Anson, E. (2007). The impact of the parental illness representation on disease management in childhood asthma. Nursing Research, 56(3), 167-174. doi:10.1097/01.NNR.0000270023.44618.a7. Zaraket, R., Al-Tannir, M. A., Bin Abdulhak, A. A., Shatila, A., & Lababidi, H. (2011). Parental perceptions and beliefs about childhood asthma: a cross-sectional study. Croatian Medical Journal, 52(5), 637-643. NURSING 596 CULMINATING PROJECT 39 Appendix A PIAMA Risk Score Factors1 1. Sex (Male=2, Female = 0) 2. Preterm birth (<37 weeks) (yes=1, no= 0) 3. Medium/low parental education (at least one parent) (yes= 1, no= 0) 4. Parental asthma (yes= 4, no=0) 5. Wheezing frequency a. 1-3 times/year (yes= 4, no=0) b. greater than or equal to four times/year (yes=7, no=0) 6. Wheezing/dyspnea apart from colds (yes=2, no=0) 7. Respiratory tract infections* a. 1-2 times/year (yes=1, no=0) b. greater than or equal to 3 times/year (yes=1, no=0) 8. Doctor\u00E2\u0080\u0099s diagnosis of eczema and eczematous rash present (yes=6, no=0) Total:_______ PIAMA RISK SCORE RISK OF ASTHMA BY SCHOOL AGE <7 <5% 8-15 6%-22% >16 25%-60% 1. Brunekreef, B., Smit, J., de Jongste, J., Neijens, H., Gerritsen, J., Postma, D., . . . van Strien, R. (2002). The prevention and incidence of asthma and mite allergy (PIAMA) birth cohort study: Design and first results. Pediatric Allergy and Immunology, 13(s15), 55-60. doi:10.1034/j.1399-3038.13.s.15.1.x. *Defined as a parental report of number of serious respiratory tract, nose, throat and/or ear infections was defined based on parental reports on the number of doctor\u00E2\u0080\u0099s office visits cause by child\u00E2\u0080\u0099s fever in combination with cough, a runny or blocked nose, or earache in last 12 months (Hafkamp-de Groen et al., 2013). NURSING 596 CULMINATING PROJECT 40 Appendix B Asthma Predictive Index1 MAJOR CRITERIA MINOR CRITERIA PARENTAL MD ASTHMA \u00C2\u00A7 MD allergic rhinitis \u00E2\u0088\u0086 MD ECZEMA \u00C2\u00A7\u00C2\u00A7 Wheezing apart from colds Eosinophilia Criteria: Loose index for the prediction of asthma: early wheezer plus at least one of the two major criteria or two of three minor criteria. Stringent index for the prediction of asthma: early frequent wheezer plus at least one of the two major criteria or two of three minor criteria. \u00C2\u00A7 History of physician diagnosis of asthma \u00C2\u00A7\u00C2\u00A7 Physician diagnosis of atopic dermatitis at age 2 or 3 \u00E2\u0088\u0086 Physician diagnosis of allergic rhinitis at age 2 or 3 1. Castro-Rodriguez, J. (2010). The asthma predictive index: A very useful tool for predicting asthma in young children. Journal of Allergy and Clinical Immunology, 126(2), 212- 216. doi:10.1016/j.jaci.2010.06.032. My Breathing Buddy A project created by: Jodi Harris, RN, BSN, MN-NP(F) Student University of British Columbia This diary is a symptom tracker for parents of children with suspected undiagnosed Asthma. Please complete applicable areas where indicated. Bring this tool to all visits to health care providers including clinic and Emergency Department visits. Have the physician or Nurse Practitioner complete each indicated area. This tool is intended for use by practitioners in symptom mapping and trend identification only. This is not a definitive diagnostic tool. Buddy, the Diagnosis Detective Demographic Information: Parent\u00E2\u0080\u0099s Name: Telephone Number: Child\u00E2\u0080\u0099s Name: Date of Birth: If found, please return to this address: _______________________________________________\t \u00C2\u00A0 My Health History: \t \u00C2\u00A0Born at _____ weeks Weight at Birth________ Complications during pregnancy ___________________________________________________ Vaginal or caesarean birth _______________________________ Hospitalizations after birth_______________________________ Medical illnesses_______________________________________ Allergies_____________________________________________ Breast fed/formula fed/both______________________________ Other important information about my child: ______________________________________________________________________________________________________ Family Medical History: My parent\u00E2\u0080\u0099s health history (including asthma or eczema): _________________________________________ Medications used:_____________________________ They are allergic to:__________________________ My parent\u00E2\u0080\u0099s health history (including asthma or eczema): _________________________________________ Medications used:_____________________________ They are allergic to:__________________________ My sibling\u00E2\u0080\u0099s health history: _________________________________________ Medications used:_____________________________ They are allergic to:__________________________ Household Environment: Smokers in house (yes or no) _________________ Smoke in the house (yes or no) _______________ We avoid places with pets (yes or no) __________ We have a pet (yes or no) __________________ My pet is a (example: cat)__________________ At home, I had some symptoms that were scary. Date: Time: My child has been sick for _________ days My child has been sick with: (check all that apply) ___Cough ___Runny Nose ___Blocked Nose ___Fever ___Earache ___Tummy Ache/Vomiting ___Rash (itchy/not itchy) ___Not able to sleep/frequent night waking I could hear a wheeze/whistle (yes or no) ________________ I heard it worse (when breathing in or out) _______________ The symptoms were worse in the (day or night) ____________ I could see my child\u00E2\u0080\u0099s breathing change, it looked like: __ faster/heavier __neck sucking in __worried/anxious __ nostrils flaring __sitting like a tripod __other:_______ I treated my child\u00E2\u0080\u0099s symptoms with these medicines: __Inhaler blue, tan, red/pink, red (circle all that apply) __Tylenol __Antibiotics __Advil __Other: _______________ My child got better in _____ days I did/did not go to the doctor because _______________________________________________ Other information that I want you to know: ______________________________________________________________________________________________ Date: Time: My child has been sick for _________ days My child has been sick with: (check all that apply) ___Cough ___Runny Nose ___Blocked Nose ___Fever ___Earache ___Tummy Ache/Vomiting ___Rash (itchy/not itchy) ___Not able to sleep/frequent night waking I could hear a wheeze/whistle (yes or no) ________________ I heard it worse (when breathing in or out) _______________ The symptoms were worse in the (day or night) ____________ I could see my child\u00E2\u0080\u0099s breathing change, it looked like: __ faster/heavier __neck sucking in __worried/anxious __ nostrils flaring __sitting like a tripod __other:_______ I treated my child\u00E2\u0080\u0099s symptoms with these medicines: __Inhaler blue, tan, red/pink, red (circle all that apply) __Tylenol __Antibiotics __Advil __Other: _______________ My child got better in _____ days I did/did not go to the doctor because _______________________________________________ Other information that I want you to know: ______________________________________________________________________________________________ We are going to the clinic! Date: Time: I brought my child to the nurse practitioner/doctor today because____________________________________________________________________________________________________ My child has been sick for _________ days My child has been sick with (check all that apply) ___Cough ___Earache ___Fever ___Not able to sleep ___frequent night waking ___Runny Nose ___Tummy Ache/Vomit ___Blocked Nose ___Rash (itchy/not itchy) I could hear a wheeze/whistle (yes or no) ____________ I heard it worse (when breathing in or out)___________ The symptoms were worse in the (day or night) ________ I could see my child\u00E2\u0080\u0099s breathing change, it looked like: __ faster/heavier __neck sucking in __worried/anxious __ nostrils flaring __sitting like a tripod __other:_______ I treated my child\u00E2\u0080\u0099s symptoms with these medicines: __Inhaler blue, tan, red/pink, red (circle all that apply) __Tylenol __Antibiotics __Advil __Other: _______________ Other information that I want you to know: __________________________________________________________________________________________________________ My diagnosis was:________________________________________ My treatment was:_______________________________________ Date: Time: I brought my child to the nurse practitioner/doctor today because____________________________________________________________________________________________________ My child has been sick for _________ days My child has been sick with (check all that apply) ___Cough ___Earache ___Fever ___Not able to sleep ___frequent night waking ___Runny Nose ___Tummy Ache/Vomit ___Blocked Nose ___Rash (itchy/not itchy) I could hear a wheeze/whistle (yes or no) ____________ I heard it worse (when breathing in or out)___________ The symptoms were worse in the (day or night) ________ I could see my child\u00E2\u0080\u0099s breathing change, it looked like: __ faster/heavier __neck sucking in __worried/anxious __ nostrils flaring __sitting like a tripod __other:_______ I treated my child\u00E2\u0080\u0099s symptoms with these medicines: __Inhaler blue, tan, red/pink, red (circle all that apply) __Tylenol __Antibiotics __Advil __Other: _______________ Other information that I want you to know: __________________________________________________________________________________________________________ My diagnosis was:________________________________________ My treatment was:_______________________________________ Time to go to the hospital! Date: Time: I brought my child to the nurse practitioner/doctor today because____________________________________________________________________________________________________ My child has been sick for _________ days My child has been sick with (check all that apply) ___Cough ___Earache ___Fever ___Not able to sleep ___frequent night waking ___Runny Nose ___Tummy Ache/Vomit ___Blocked Nose ___Rash (itchy/not itchy) I could hear a wheeze/whistle (yes or no) ____________ I heard it worse (when breathing in or out)___________ The symptoms were worse in the (day or night) ________ I could see my child\u00E2\u0080\u0099s breathing change, it looked like: __ faster/heavier __neck sucking in __worried/anxious __ nostrils flaring __sitting like a tripod __other:_______ I treated my child\u00E2\u0080\u0099s symptoms with these medicines: __Inhaler blue, tan, red/pink, red (circle all that apply) __Tylenol __Antibiotics __Advil __Other: _______________ Other information that I want you to know: __________________________________________________________________________________________________________ My diagnosis was:________________________________________ My treatment was:_______________________________________ Date: Time: I brought my child to the nurse practitioner/doctor today because_______________________________________________ _____________________________________________________ My child has been sick for _________ days My child has been sick with (check all that apply) ___Cough ___Earache ___Fever ___Not able to sleep ___frequent night waking ___Runny Nose ___Tummy Ache/Vomit ___Blocked Nose ___Rash (itchy/not itchy) I could hear a wheeze/whistle (yes or no) ____________ I heard it worse (when breathing in or out)___________ The symptoms were worse in the (day or night) ________ I could see my child\u00E2\u0080\u0099s breathing change, it looked like: __ faster/heavier __neck sucking in __worried/anxious __ nostrils flaring __sitting like a tripod __other:_______ I treated my child\u00E2\u0080\u0099s symptoms with these medicines: __Inhaler blue, tan, red/pink, red (circle all that apply) __Tylenol __Antibiotics __Advil __Other: _______________ Other information that I want you to know: __________________________________________________________________________________________________________ My diagnosis was:________________________________________ My treatment was:_______________________________________ Notes: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ References Asthma Clinic (2014) About Asthma. Retrieved from http://www.cw.bc.ca/library/pdf/pamphlets /BCCH1108_AboutAsthma_2014.pdf on March 28, 2017. Brunekreef, B., Smit, J., de Jongste, J., Neijens, H., Gerritsen, J., Postma, D., . . . van Strien, R. (2002). The prevention and incidence of asthma and mite allergy (PIAMA) birth cohort study: Design and first results. Pediatric Allergy and Immunology, 13(s15), 55-60. doi:10.1034/j.1399-3038.13.s.15.1.x. Castro-Rodriguez, J. (2010). The asthma predictive index: A very useful tool for predicting asthma in young children. Journal of Allergy and Clinical Immunology, 126(2), 212-216. doi:10.1016/j.jaci.2010.06.032. "@en . "Graduating Project"@en . "10.14288/1.0343582"@en . "eng"@en . "Unreviewed"@en . "Vancouver : University of British Columbia Library"@en . "Attribution-NonCommercial-NoDerivatives 4.0 International"@* . "http://creativecommons.org/licenses/by-nc-nd/4.0/"@* . "Graduate"@en . "University of British Columbia. NURS 596"@en . "Asthma"@en . "Diagnosis"@en . "Child"@en . "Children"@en . "Preschool"@en . "Pediatrics"@en . "Respiratory Tract Diseases"@en . "Chronic Disease"@en . "Health Promotion"@en . "A Diary for Parents of Children with Suspected Asthma"@en . "Text"@en . "Still Image"@en . "http://hdl.handle.net/2429/61196"@en .