Asthma- Exam 2 (8-10 Q)

There are several children in the ER waiting area who all have asthma. The nurse has only one room left in the ER. Based on the following information, which child should be seen first? -A 16 year old who is speaking in short sentences, is wheezing, is sitting upright, and has an oxygen saturation of 94%. -A 9 year old who is quiet, is pale in color and is wheezing bilaterally with an oxygen saturation of 92%. -A 12 month old who has a mild cry, is pale in color, has diminished breath sounds, and has an oxygen saturation of 92%. -A 5 year old who is speaking in complete sentences, is pink in color, is wheezing bilaterally, and has an oxygen saturation of 92%.

-A 12 month old who has a mild cry, is pale in color, has diminished breath sounds, and has an oxygen saturation of 92%.

The nurse is caring for a client who has admitted for asthma. The client has O2 sats of 91 % exhibits audible wheezes and is using accessory muscles. Which class of medication would the nurse anticipate administering. -A beta2 agonist -An antibiotic -A beta blocker -An antiviral

-A beta2 agonist

Asthma Triggers

-Allergens -Respiratory tract infection -Exercise -Inhaled irritants -Emotional upsets -environment -respiratory infections (viral mainly) -exercising (loss of heat or water) -NSAIDS, ASA, Beta blockers, sulfites

Diagnostic studies for Asthma

Health history Pulmonary function testing (PFTs): Forced expiratory volume in 1 second (FEV1)/ Forced vital capacity (FVC). O2 sat ABGs CXR - may show hyperinflation. Usually normal. PEF meter Histamine or methacholine challenge test - helps when spirometry isn't diagnostic

A child with asthma states, "I want to play some sports like my friends. What can I do?" The nurse responds to the child based on the understanding of which of the following? -Physical activities are inappropriate for children with asthma -Children with asthma must be excluded from team sports -Most children with asthma can participate in sports if the asthma is controlled -Vigorous physical exercise frequently precipitates an asthmatic episode

Most children with asthma can participate in sports if the asthma is controlled

Mast Cell Stabilizers Non-steroidal anti-inflammatory Cromolyn (Intal)-nebulizer or MDI Nedocromil (Tilade)-MDI

Non-steroidal anti-inflammatory Inhibit the IgE-mediated release of inflammatory mediator form mast cells. Suppress other inflammatory cells. Used for asthma prophylactically if allergen is causative agent. Takes several weeks before clinical response occurs. Side Effects: irritant to throat, bronchospasms

Medication Treatment: Important to note to pt and family?

One of the most important items to teach patients about medication is the difference between medications for quick relief or rescue and control medications. It is imperative that they understand which inhaler or nebulizer vial is their short acting bronchodilator.

Mucolytics Hypertonic saline Acetylcysteine

React with mucus to make a watery consistency Cough becomes more productive with use Administered by inhalation Can trigger bronchospasm Side effects: stomatitis, nausea, vomiting, feve

Methylxanthines: ◦Cause CNS excitation ◦Bronchodilation Theophylline (Theo-24) Aminophylline

Side effects: dysrhythmias, seizures , nausea, diarrhea, restlessness

Asthma Nursing care:

Stabilizing of patient monitoring for respiratory changes monitor patients for response to medications and increasing respiratory distress improve oxygenation positioning, decreasing stimuli, decreasing oxygen demands, and providing humidified supplemental oxygen therapy.

Critical finding is Silent chest, why?

The absence of wheezing or diminished breath sounds could indicate a decrease or lack of air movement as a result of exhaustion or extreme narrowing of the airway. This is a sign of impending respiratory failure.

Pathophysiology of Asthma

Asthma is a chronic inflammatory disorder with reversible airway obstruction caused by bronchial hyperresponsiveness. Exposure to allergens or irritants begins an inflammatory process within the lungs and airways

IGE antagonist Omalizumab (Xolair)

Decreases circulating free IgE levels Used for moderate to severe persistant asthma that cannot be controlled by with inhaled corticosteroids Administered via subcutaneous injection q 2 to 4 weeks Side Effect: headache, tired feeling, joint or muscle pain, dizziness,

A 10 year old child with asthma is treated for acute exacerbation in the emergency department. The nurse caring for the child should monitor for which sign, knowing that it indicates worsening of the condition? Pulse rate of 90 beats per minute Respirations of 18 breaths per minute Diminished wheezing Warm, dry skin

Diminished wheezing

Key assessments for asthma

inspiratory & expiratory wheezing, dry hacking cough, increased WOB, tachypnea, anxiety, retractions, and tachycardia.

Anti-inflammatory Corticosteriods Inhaled - Flovent Oral - Prednisone IV - Solumedrol, Decadron

oMost effective anti-asthmatic drug oWork by suppressing inflammation oDecrease bronchial hyperactivity oUsually inhaled, but can be IV or oral. Side effects:Thrush Inhaled have less systemic effects so you will not see side effects of increased appetite and mood swings that are seen in oral and IV.

Symptoms of Hypoxia early- RAT late- BED Infant- FINES

restless anxiety tachycardia bradycardia extreme restlessness dyspnea feeding diff inspiratory stridor nares flare expiratory grunting sternal retractions

Asthma is Categorized in 4 groups based on most severe symptoms

•Mild Intermittent - symptoms occur less than 2 times a week , No limitation on activity •Mild persistent - symptoms occur more than twice a week but not daily , minor limitations on activity •Moderate persistent - daily symptoms, with exacerbations twice a week , some limitation on activity •Severe persistent - Symptoms occur continually, frequent daily exacerbations, limits physical activity and quality of life

Acute care interventions:

•Ongoing Monitoring and Assessment •Humidified O2 •Hydration •Patient Positioning •Quiet Environment, Rest, Support •Medication •Patient and Family Teaching

Client Education

•PEFR measurement for asthma - peak flow meter •Use of medication, purpose, and side effects •Use of non-prescription meds •Self care measures

Bronchodilators B2 adrenergic agonist:

◦Act on beta 2 receptors to promote bronchodilation ◦Suppress histamine release in the lungs ◦Most effective drug for relieving bronchospasm Short acting ◦Albuterol (other options are Bitolterol mesylate, Levalbuteral, Pirbuterol) Long acting (will also see in combination medications) ◦Arformoterol, Salmeterol Side effects: Tachycardia, anxiety, tremors

Peak Expiratory Flow Result

◦Green- 80-100% ◦ ◦Yellow- 50-80%, exacerbation possible or asthma not well managed ◦ ◦Red- Below 50%. Immediate bronchodilator needed; contact health care provider

How to use a peak flow meter

1) move the indicator to the bottom of the numbered scale 2) stand up 3) take a deep breath, filling your lungs completely 4) place the mouthpiece in your mouth and close your lips around it but do not put your tongue in the hole 5) blow out as hard and fast as you can in a single blow

Respiratory Drug Therapy: Routes of Administration

Inhalation treatments are the desired method (less systemic effect) ◦Nebulizer Treatments ◦Metered- Dose inhaler ◦Spacer ◦Dry powder Inhaler Oral Intravenous Subcutaneous

The nurse is with a client using an albuterol MDI. The client takes two puffs in rapid succession. Which intervention is the priority? -Call the pharmacy and order spacer for this client. -Instruct client to rinse the mouth after use. -Instruct the client about proper techniques for using and MDI inhaler -Notify the HCP that the client needs to resume nebulizer treatments

Instruct the client about proper techniques for using and MDI inhaler

Leukotriene Modifiers Zafirlukast (Accolate)-oral tablets Montelukasat (Singular)-oral tablets maintenance or acute?

Interfere with the synthesis or block the action of leukotrienes. Not for use in acute asthma Used mainly for maintenance & prophylactic therapy. Effective for add on therapy to reduce not replaced inhaled corticosteroids. Side effects: headache, dizziness, nausea, fatigue, abdominal pain, bronchospasms

Anticholinergics: ◦Cause bronchial dilation ◦Administered by inhalation ◦Drugs approved to treat COPD

Ipratropium (Atrovent) ◦May be given in combination with albuterol (Duoneb) Tiotropium (Spiriva)- has a longer duration, and can be administered less often. Side effects? Dry mouth, hoarseness