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Asthma medical, nursing managements
1. ASTHMA
MEDICAL MANAGEMENT
IDEAL
The goal is to allow the person with asthma to live a normal life
DIAGNOSTIC EVALUATION
Patients 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
2. to identify causative allergens
Chest X-rays
hyperinflation with areas of focal atelectasis
to exclude other lung diseases in new onset asthma in adult
Before 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 include
obstructive 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 don't 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 doesn't respond to treatment, whose airways remain obstructed, and who has increasing respiratory
difficulty is at risk for status asthmaticus
3. 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 infection
Other Measures
Environmental control
4. 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 treatment
References:
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.
5. NURSING MANAGEMENT
IDEAL
NURSING ASSESSMENT
Review patient's 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 patient's degree of adherence with medications/management regimen
Observe inhalation technique
NURSING 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
6. 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
regimen
NURSING INTERVENTIONS
During an acute attack, proceed as follows:
First, assess the severity of asthma.
Administer the prescribed treatments and assess the patient's response.
Place the patient in high Fowler's 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 patient's 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 they're 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 patient's cough, and note whether it's 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.
7. During long-term care
Monitor the patient's 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 patient's 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 patient's 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.
8. 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
9. work requirements.
EVALUATION: EXPECTED OUTCOMES
Symptoms (wheezing, coughing, chest tightness) reduced; peak flow improved
Verbalizes relief of anxiety
References:
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.