ASTHMA MEDICAL MANAGEMENT IDEAL The goal is to allow the person with asthma to live a normal lifeDIAGNOSTIC EVALUATIONPatients with asthma commonly show these abnormalities in their test results: Pulmonary function tests signs of airway obstruction (decreased peak expiratory flow rates and forced expiratory volume in 1 second) low-normal or decreased vital capacity increased total lung and residual capacity may be normal between attacks >12% increase over baseline in forced expiratory volume in first second of exhalation (FEV1) following inhalation of bronchodilator. Peak flow > 20% variability between AM and PM measurements Pulse oximetry decreased arterial oxygen saturation (SaO2) Arterial blood gas (ABG) analysis provides the best indication of the severity of an attack in acutely severe asthma, the partial pressure of arterial oxygen (PaO 2) is less than 60 mm Hg, the partial pressure of arterial carbon dioxide (PaCO2) is 40 mm Hg or more, and pH is usually decreased Complete blood count with differential increased eosinophil count Laboratory increased levels of IgE may be seen in atopic asthma Bronchial methacholine challenge demonstrates airway hyperreactivity by the inhalation of a cholinergic agent in serial concentrations delivered by nebulization a positive response is indicated by a 20% decrease in FEV1 from baseline Skin testing
to identify causative allergens Chest X-rays hyperinflation with areas of focal atelectasis to exclude other lung diseases in new onset asthma in adultBefore initiating tests for asthma, rule out other causes of airway obstruction and wheezing.In children, such causes include cystic fibrosis, tumors of the bronchi or mediastinum, and acute viral bronchitis; in adults, other causes includeobstructive pulmonary disease, heart failure, and epiglottitis.TREATMENT Aims to decrease bronchoconstriction, reduce bronchial airway edema, and increase pulmonary ventilation. After an acute episode, treatment focuses on avoiding or removing precipitating factors, such as environmental allergens or irritants Desensitization If a specific antigen is causing the asthma, the patient may be desensitized through a series of injections of limited amounts of that antigen. Aims to curb his immune response to the antigen Antibiotic Prescribed if an infection is causing the asthma Drug Therapy most effective when begun soon after the onset of symptoms For relief of symptoms in adults and children older than age 5, a short-acting, inhaled beta2-adrenergic agonist for bronchodilation may be used, and a course of systemic corticosteroids may be needed. The goal of therapy is to control the asthma with minimal or no adverse reactions to the medication. Acute attacks that dont respond to treatment may require hospital care, an inhaled or S.C. beta2-adrenergic agonist (in three doses over 60 to 90 minutes) and, possibly, oxygen for hypoxemia. If the patient responds poorly, a systemic corticosteroid and, possibly, S.C. epinephrine may help. Beta2-adrenergic agonist inhalation continues hourly. I.V. aminophylline may be added to the regimen, and I.V. fluid therapy is started. Mechanical ventilation May be required for patients who doesnt respond to treatment, whose airways remain obstructed, and who has increasing respiratory difficulty is at risk for status asthmaticus
Treatment of status asthmaticus consists of aggressive drug therapy: beta2-adrenergic agonist by nebulizer every 30 to 60 minutes S.C. epinephrine I.V. corticosteroid I.V. aminophylline oxygen administration I.V. fluid therapy, and intubation Mechanical ventilation for hypercapnic respiratory failure (PaCO2 of 40 mm Hg or more).Quick-relief Medications Short-acting bronchodilators by inhalation Beta-agonists, such as albuterol (Proventil, Ventolin), pirbuterol (Maxair), and levalbuterol (Xopenex) Anticholinergic agent ipratropium bromide (Atrovent) Systemic corticosteroids (short course)Long-term Controllers Inhaled corticosteroids, such as triamcinolone (Azmacort), beclomethasone (Vanceril, Beclovent, QVAR), fluticasone (Flovent), budesonide (Pulmicort), flunisolide (AeroBid) Long-acting inhaled beta-agonists include salmeterol (Serevent) and formoterol (Foradil) Combination inhalers, such as fluticasone and salmeterol (Advair) Leukotriene modifiers, such as montelukast (Singulair), zafirlukast (Accolate) Inhaled mast cell stabilizers include cromolyn sodium (Intal) and nedocromil (Tilade) Long-acting oral beta-agonists such as albuterol extended-release tablets [Volmax]) Oral corticosteroids (maintenance dose) Methylxanthines such as theophylline (Theo-24, Uniphyl, Theo-Dur) IgE blocker (omalizumab [Xolair]) can be added to standard maintenance therapy to reduce exacerbations o subcutaneous injection every 2 to 4 weeks o The most common adverse reactions are injection site reactions and viral infectionOther Measures Environmental control
Immunotherapy Avoidance of foods that contain tartrazine (yellow dye no. 5) in aspirin-sensitive patients. Exercise Regular aerobic exercise should be encouraged. Use of an inhaled beta-adrenergic agonist or cromolyn taken 15 to 20 minutes before exercise will decrease exercise-induced bronchospasm. Antibiotics are prescribed only during acute exacerbations if signs and symptoms of bacterial infection are present. Alternative and complementary therapies have been suggested for acute and chronic asthma control Acupuncture herbal preparations yoga chiropractic treatment none is a substitute for usual medical treatmentReferences: th Asthma Management Handbook 6 Edition. National Asthma Council Australia: 2006. th Baum, Gerald L. Baum’s Textbook of Pulmonary Diseases Practice, 7 Edition. Lippincott Williams & Wilkins Publishers: 2003. th McCann, J. A., et al. Diseases: A Nursing Process Approach to Excellent Care, 4 Edition. Lippincott Williams & Wilkins: 2006. th Nettina, Sandra M., Mills, Elizabeth Jacqueline. Lippincott Manual of Nursing Practice, 8 Edition. Lippincott Williams & Wilkins: 2006. Smeltzer, C.S., Bare, B.G., Hinkle, J.L., Cheever, K.H., Brunner and Suddarth’s Textbook of Medical-Surgical Nursing 11th Ed. United States of America: Lippincott Williams and Wilkins, 2008. rd Sommers, M. S., Johnson, S. A., Beery, T. A. Diseases and Disorders: A Nursing Therapeutics Manual, 3 Edition. F. A. Davis Company: 2007.
NURSING MANAGEMENT IDEALNURSING ASSESSMENT Review patients record: ask about coughing, dyspnea, chest tightness, wheezing, exertional changes, and increased mucous production Observe the patient and assess the rate, depth, and character of respirations, especially on expiration; observe for hyperinflation. Assess peak flow Auscultate the chest for breath sounds or wheezing Assess for triggers of asthma that include the following: o Allergens o Respiratory infections o Inhalation of irritating substances (dust, fumes, gases) o Environmental factors (weather, air pollution, and humidity) o Exercise, particularly in cold weather o Aspirin and its derivatives o Sulfite-containing agents used as food preservatives o Emotional factors After acute episode subsides, attempt to determine patients degree of adherence with medications/management regimen Observe inhalation techniqueNURSING DIAGNOSES (PRIORITIZED) Ineffective airway clearance Ineffective breathing pattern Impaired gas exchange Fear Anxiety Deficient knowledge (treatment regimen)KEY OUTCOMES The patient will: maintain a patent airway
maintain adequate ventilation and oxygenation maintain a respiratory rate within five breaths of baseline express feelings of comfort, either verbally or through behavior Verbalize concerns and fears related to his condition. The patient and family will: indicate verbally or through demonstration that they understand how to administer medications and comply with the treatment regimenNURSING INTERVENTIONSDuring an acute attack, proceed as follows: First, assess the severity of asthma. Administer the prescribed treatments and assess the patients response. Place the patient in high Fowlers position. Encourage pursed-lip and diaphragmatic breathing. Help patient to relax. Administer prescribed humidified oxygen by nasal cannula at 2 L/minute to ease breathing and to increase SaO 2. Later, adjust oxygen according to the patients vital signs and ABG levels. Anticipate intubation and mechanical ventilation if the patient fails to maintain adequate oxygenation. Monitor serum theophylline levels to make sure theyre in the therapeutic range. Observe patient for signs and symptoms of theophylline toxicity (vomiting, diarrhea, and headache), as well as for signs of subtherapeutic dosage (respiratory distress and increased wheezing). Observe the frequency and severity of patients cough, and note whether its productive. Auscultate lungs, noting adventitious or absent breath sounds. If cough is unproductive and rhonchi are present, teach effective coughing techniques. If the patient can tolerate postural drainage and chest percussion, perform these procedures to clear secretions. Suction an intubated patient as needed. Treat dehydration with I.V. fluids until the patient can tolerate oral fluids, which will help loosen secretions. If conservative treatment fails to improve the airway obstruction, anticipate bronchoscopy or bronchial lavage when a lobe or larger area collapses.
During long-term care Monitor the patients respiratory status to detect baseline changes to assess response to treatment to prevent or detect complications Auscultate the lungs frequently, noting the degree of wheezing and quality of air movement. Review ABG levels, pulmonary function test results, and SaO 2 readings. If the patient is taking a systemic corticosteroid, observe for complications, such as an elevated blood glucose level and friable skin and bruising. Cushingoid effects resulting from long-term use of a corticosteroid may be minimized by alternate-day dosing or use of a prescribed inhaled corticosteroid. If the patient is taking an inhaled corticosteroid, watch for signs of candidal infection in the mouth and pharynx. Using an extender device and rinsing the mouth afterward may prevent this. Observe the patients anxiety level. Measures to reduce hypoxemia and breathlessness should help relieve anxiety. Keep the room temperature comfortable, and use an air conditioner or a fan in hot, humid weather. Control exercise-induced asthma by instructing the patient to use a bronchodilator or cromolyn 30 minutes before exercise. Instruct pt to use pursed-lip breathing while exercising.Community and Home Care Considerations Initiate peak flow monitoring as ordered by health care provider. This may be done twice daily by the patient with persistent asthma. Provide written and verbal instruction and have the patient demonstrate the procedure. Once optimal asthma control is obtained, daily peak flow measurements in the early morning and early afternoon should be used during a 2- to 3-week period to determine the patients personal best. The personal best peak flow measurement will be used to monitor control and to guide self-therapy in an individualized action plan. Provide written and verbal instruction on an action plan for self-management of asthma exacerbation as outlined by the health care provider.PATIENT EDUCATION AND HEALTH MAINTENANCE Provide information on the nature of asthma and methods of treatment. Teach the patient and his family to avoid known a llergens and irritants.
Teach the patient about his medications, including proper dosages, administration instructions, and adverse effects. Provide information regarding medications, including the difference between long-term controllers and quick relief medications and the proper use of inhalers and spacer devices Stress avoiding overuse of inhalers and nebulizers. Ensure that patient understands that long-acting bronchodilating inhalers such as salmeterol are not effective for asthma exacerbations. Teach the patient how to use a metered-dose inhaler and nebulization equipment. If he has difficulty using an inhaler, he may need an extender device to optimize drug delivery and lower the risk of candidal infection with an orally inhaled corticosteroid. Help patient to identify what triggers asthma, warning signs of an impending attack, and strategies for preventing and treating an attack. Teach adaptive breathing techniques and breathing exercises such as pursed-lip breathing. If the patient has moderate to severe asthma, explain how to use a peak flow meter to measure the degree of airway obstruction. Tell him to keep a record of peak flow readings and to bring it to medical appointments. Explain the importance of calling the physician at once if the peak flow drops suddenly (this may signal severe respiratory problems). Discuss environmental control. o Avoid people with respiratory infections. o Avoid substances and situations known to precipitate bronchospasm, such as allergens, irritants, strong odors, gases, fumes, and smoke. o Wear a mask if cold weather precipitates bronchospasm. o Stay inside when air pollution is high. Tell the patient to notify the physician if he develops a fever above 100°F (37.8°C), chest pain, shortness of breath without coughing or exercising, or uncontrollable coughing. Teach the patient diaphragmatic and pursed-lip breathing as well as effective coughing techniques. Promote optimal health practices, including nutrition, rest, and exercise. o Encourage regular exercise to improve cardiorespiratory and musculoskeletal conditioning. o Drink at least 3 qt (3 L) of fluids daily to help loosen secretions and maintain hydration. o Try to avoid upsetting situations. o Use relaxation techniques, biofeedback management. o Use community resources for smoking cessation classes, stress management, exercises for relaxation, asthma support groups, etc. Make sure that patient knows with whom to follow up and the frequency of follow-up. Discuss with patient how to overcome any barriers to follow-up, such as transportation, limited office or clinic hours, child care, and
work requirements.EVALUATION: EXPECTED OUTCOMES Symptoms (wheezing, coughing, chest tightness) reduced; peak flow improved Verbalizes relief of anxietyReferences: th McCann, J. A., et al. Diseases: A Nursing Process Approach to Excellent Care, 4 Edition. Lippincott Williams & Wilkins: 2006. th Nettina, Sandra M., Mills, Elizabeth Jacqueline. Lippincott Manual of Nursing Practice, 8 Edition. Lippincott Williams & Wilkins: 2006. Smeltzer, C.S., Bare, B.G., Hinkle, J.L., Cheever, K.H., Brunner and Suddarth’s Textbook of Medical-Surgical Nursing 11th Ed. United States of America: Lippincott Williams and Wilkins, 2008. rd Sommers, M. S., Johnson, S. A., Beery, T. A. Diseases and Disorders: A Nursing Therapeutics Manual, 3 Edition. F. A. Davis Company: 2007.