Asthma Nursing Interventions

Genetic factors

Asthma can be inherited

Immune factors

People who are exposed to certain infections early in life, use few antibiotics, are exposed to other children, or live in the country or with pets have a lower incidence of asthma

Leukotriene Modifiers

1. Montelukast 2. Have both bronchiodilator and anti-inflammatory effects. 3. Should not be used for reversal of bronchospasm in acute asthma attacks 4. Are used only for prophylactic and maintenance therapy

Asthma

A chronic Inflammatory disorder of the airways. The chronic inflammation leads to recurrent episodes of wheezing, breathlessness, chest tightness, and cough, particularly at night or early in the morning. The variable airflow obstruction is usually reversilbe

An acute asthma attack

Patients that "can't get a deep breath" during an acute attack usually sit upright or slightly bent forward using the accessory muscles of respiration to get enough air. The more difficult the breathing becomes, the more anxious the patient feels.

GERD factors

can trigger broncho constriction and cause aspiration

Drug Therapy

1. Anti-inflammatory drugs 2. Bronchiodilators

Clinical manifestations of asthma

1. Wheezing 2. Coughing 3. dyspnea 4. chest tightness Occur after or upon exposure to an asthma trigger.

Niox Mino

A hand-held point of care device that measures airway inflammation related to asthma. It measures fractional exhaled nitric oxide (FENO). Nitric oxide levels are increased in the breath of people who have asthma and decreased with oral and inhaled corticosteroids and leukotriene treatment. This allows for the health care provider to rely on FENO measures versus a patient's symptoms and lung function.

Collaborative Care

Achieving rapid control of the symptoms is the goal to return the patient to his or her daily functioning at the best possible level.

Moderate exacerbations of asthma

Dyspnea interferes with usual activities and peak flow is 40% to 60% of personal best. In this situation, the person usually comes to the ED or doctors office to get help. Relief is provided with a SABA (albuterol) and oral corticosteroids. The patients symptoms may persist for several days even after the corticosteroids are started. Oxygen can be used for both mild and moderate exacerbations to maintain SpO2 at 90% or greater.

Nursing assessment

If the patient can speak and is not in acute distress, take a detailed history, including any preciptating factors and what has helped to alleviate attacks in the past

SAFETY ALERT

If the patient has been wheezing and then there is an absence of a wheeze and the patient is obviously struggling, this is a life-threatening situation that may require mechanical ventilation.

Patients with intermittent asthma require this for treatment.

SABAS such as albuterol.

Drug and food additive factors

The asthma triad: 1. Nasal polyps 2. asthma 3. sensitivity to aspirin and NSAIDS (salicylic acid in these drugs cause an asthma attack) 4. yellow dye #5 found in foods 5. Sulfiting agents (Food preservatives) found in fruits, wine, beer, and in salad bars ***Food allergies triggering asthma reactions in adults are rare. Avoidance diets are not recommended until an allergy has been demonstrated, usually by oral challenges

FENO

May be used to assess a patient's adherence to therapy or to determine if he or she needs more anti-inflammatory meds. FENO is also a predictor of loss of asthma control and exacerbations.

Occupational factors

1, May not occur until after years of exposure 2. Agriculture worker 3. baker 4. hospital worker 5. plastics manufacturer 6. beautician

Acute Intervention of Asthma

1. A goal in asthma care is to maximize the patient's ability to safely manage acute asthma exacerbations using an asthma action plan. 2. Action plans are important for people with moderate to severe persistent asthma. The action plan dictates what peak flow reading calls for a change in asthma care to gain control. 3. The patient can take 2 to 4 puffs of a SABA every 20 minutes three times as a rescue plan. If symptoms persist or if the patient's peak flow is less than 50% of personal best, the EMS needs to be contacted immediately 4. When apatient is in the hospital with an acute exaccerbation, it is important to monitor the patient's cardiac and resp. systems. HTis includes auscultating lung sounds, taking heart and resp rates and BP readings and monitoring ABGS, pulse oximetry and peak flow. 5. Louder wheezing may actually occur in airways that are responding to therapy as airflow increases. As improvement continues, wheezing decreases and breath sounds increase.

SABAS

1. Albuterol and pirbuterol 2. Inhaled SABAS are the most effective drugs for relieving bronschospasms 3. Are known as rescue drugs 4. Have an onset action within minutes and are effective for 4 to 8 hours 5. Overuse can cause rebound bronchospasms 6. Are not used for long-term control 7 should not be used alone for persistent asthma 8. Are used for quick relief in any stage of asthma and should be with the patient at all times for that matter

Corticosteroids

1. Are the most effective long-term drug 2. Are first line of therapy for patients with persistent asthma requiring 2 through 6 therapies 3. Usually must be administered 1 to2 weeks before maximum therapeutic effects can be seen 4. Fluticasone begins to have therapeutic effects in 24 hours (needs to be administered on a fixed schedule 5. Corticosteroids (ICSs) at high dosages can cause easy bruising, yeast infection of the mouth, hoarseness, and dry cough caused by inhalation of corticosteroids. 6. These problems can be reduced by gargling with water or mouth wash after each use 7. Using a spacer can help to get more corticosteroids in the lungs during inhalation. 8. Women(premenopausal) who take corticosteroids should take adequate amounts of calcium and vitamin D and participate in regular weight bearing exercise to prevent osteoporosis fro occuring or getting worse. 9. To gain prompt control during acute exacerbations of asthma, short courses of corticosteroids are administered orally.

Nebulizers

1. Convert drug solutions into mists 2. Are for individuals with severe asthma or who have difficulty with MDI inhalation 3. Is easy to use 4. Medications used are albuterol and ipratropium 5. Patietn must inhale slowly and deeply thorugh the mouth and hold inspirations for 2 to 3 seconds 6. Use deep diapraghmic breathing and breath normally in between these large forced breaths to prevent dizziness and alveolar hypoventilation 7. After treatment instruct the patient to cough effectively 8 Wash daily in soap and water, rinse with water and soak for 20 to 30 minutes in a 1:1 white vinegar-water solution, followed by a water rinse and air drying.

Anti-inflammatory drugs

1. Corticosteroids 2. Leukotriene Modifiers 3. Ant-IgE

Important nursing goal during an acute attack

1. Decrease the patient's sense of panic. Use a calm, quiet, reassuring attitude to help the patient relax. -It is also very important to: 1. Position the patient in a comfortable sitting position to maximize chest expansion 2. Stay with the patient until resp rate has slowed 3. Talk them down by making direct eye contact and using a firm, calm voice to coach the patient to use pursed-lip breathing 4. When the attack is over, provide a quiet and calm environment for the patient to get rest 5. When the pateitn has recovered from exhaustion, try to obtain a helath history and pattern of asthma along with a physical assessment.

MDI

1. Dosing is accomplished in 1 or 2 puffs 2. A spacer can be used on some MDIs to reduce the amount of drug delivered to the oropharynx and improve the amount delivered to the lungs 3. THey have an Ozone friendly repelent (HFA) 4. Priming varies widely so read the package insert with the patient 5. SHould be cleaned by removing the dust cap and rinsing the holder (not medication chamber), in warm water at least two times per week 6. One of the major problems is the potential for overuse (more than 2 cannisters a month) rather than seeking medical care. 7. Shaking the cannister and floating it in water are NOT accurate ways to tell if the cannister is empty 8. Hold breath for 10 seconds after each puff 9. Should breath in slowly and deeply through mouth 10 shake well 11. Use a spacer with inhaled corticosteroids

DPI

1. Dry powdered medication 2. No spacer is required 3. Counts the number of blisters left 4.Do not expose to humidity due to clumping 5. Use a quick, deep breath when inhaling.

Risk Factors for asthma

1. Genetics 2.Immune response 3. Allergens 4. Exercise 5. Air pollutants 6. Occupational factors 7. Respiratory tract infections 8. Nose and sinus problems 9 Drugs and food additives 10. GERD 11. Psychological factors 12. Obesity

Peak Flow Meter

1. Peak flow measurement should be taken when you wake up and before taking medicine 2. Write down the number every day in a diary. 3. It is important for a person with asthma to find their personal best peak flow number because it sets the basis for treatment 4. To find personal best peak flow number, take peak flow reading for 2-3 weeks twice a day between 12 and 2pm and 15 to 20 minutes after taking a SABA

Severe and life threatening exacerbations

1. Repetative and continuous SABA administration is provided in the ED 2. Initially 3 treatments of SABA are given 20 to 30 minutes apart. Then more SABA is given depending on the patient's airflow, improvement and side effects. The person with severe asthma exacerbation usually gets relief from the SABA plus ipratropium. The patient with life threatening asthma exacerbation has minimal, if little relief from the same medications. -After the initial treatment, nebulized SABAS are continued for several days even after clinical improvment is noted.

Bronchodilators

1. SABAS 2. LABAS 3. Methylxanthines (theophylline) 4. Anticholinergic drugs

LABAS

1. Salmeterol 2. Are effective for 12 hours 3. Are added to a daily dose of corticosteroids for long-term control for moderate to severe persistent asthma and prevention of symptoms, particularly at night 4. When added to a patient's daily regimen of corticosteroids, they decrease the need for SABAs and allow patients to achieve better asthma control with a lower dose of corticosteroids 5. They should never be used as monotherapy for asthma, and should only be used of the patient is on a corticosteroid. 6. Teach the patient that these drugs are only used once every 12 hours and should not be used to attain quick relief from bronchospasm. 7. Should not be used to treat wheezing that is getting worse. 8. ALWAYS use a SABA to treat Sudden Wheezing. 9. Should be added to the treatment plan only if other controller medicines do not control asthma.

Methylxanthines

1. Theophylline 2. Are used only as an alternative therapy for step 2 care in mild persisten asthma 3. are not first line controller meds 4. Instruct patient to report signs of toxicity: nausea, vomiting, seizures, insomnia 5. Avoid caffeine

Respiratory tract Infections (viral not bacterial) factors

1. are the major precipitator in an acute asthma attack

Air pollutant factors

1. cigarette smoke 2. car exhaust 3. wood smoke 4. Ozone alert days where air pollutants are high outside

Examination of a patient during an acute attack reveal signs of:

1. hypoxemia 2. restlessness 3. anxiety 4. inappropriate behavior 5. Increased pulse and BP 6. Resps. are greater than 30 7. Patient has difficulty completing sentences when speaking 8. Severely diminished breath sounds "silent chest" indicate severe obstruction and impending respiratory failure 9. A the episode resolves, coughing produces thick, stringy mucus

Anticholinergic drugs

1. ipratropium 2. Are used for quick relief in patients unable to tolerate SABAS 3. Are used for the patietn in severe asthma exacerbations in emergency situations, often nebulized with a SABA. 4. They have no role in the treatment of asthma 5. Onset of action is slower than albuterol, peaking at 30 min to 1 hour and lasting 4 to 6 hours 6. Side effect is a dry mouth

Nose and sinus problem factors

Acute and chronic sinusitis may worsen asthma

Allergen factors

Cockroaches, fury animals, fungi, and molds can all trigger an asthma attack

Exercise factors

Exercise induced asthma occurs after vigorous exercise, not during it (jogging, walking briskly, aerobics, climbing stairs). Symptoms are pronounced during activities where there is exposure to cold, dry air. (downhill skiing)

Life threatening asthma

In life-threatening asthma, IV corticosteroids (methylpredniolone) are administered every 4 to 6 hours, then the patient is started on oral corticosteroids. -The length of oral prednisone treatment for both severe and life-threatening asthma is 10 days after discharge. -The patient requires intubation and mechanical ventilation if there is no response to treatment. The patient is provided with 100% oxygen, hourly or continuously nebulized SABA, IV corticosteroids adn possibly any other adjunctive therapies.

Severe asthma

In severe asthma, oral corticosteroids are given to patients who do not respond to the initial SABA

PFTs

Pulmonary function test diagnose asthma

Cough variant asthma

Some patients with asthma have cough as their only symptom. It may be unproductive and have thick, tenacious, white, gelatinous mucus, which makes their removal difficult

Psychologic factors

Symptoms of asthma worsen with stress, crying, laughing, anger, fear, panic, anxiety

Mild exacerbations of asthma

The patient has difficulty breathing only with activity and may fell that he or she cannot get enough air. The peak flow is greater than 70% of the patients personal best, and usually the symptoms are relieved at home with albuterol delivered via a nebulizer or MDI with a space. For any classification in an asthma plan, patients are instructed to take 2 to 4 puffs of albuterol every 20 min three times to gain rapid control of symptoms. Occasionally, a short course of oral corticosteroids is needed to decrease airway inflammation

Severe and life-threatening Asthma exaccerbations

These occur when the patient is at rest and the patient speaks in words, not sentences, because of the difficulty in breathing and perspire profusely. They become drowsy and confused as the ABGs deteriorate, breath sounds are difficult to hear and there is no wheezing present. Resps. are higher than 30 and pulse is greater than 120. Accessory muscles in the neck are straining to lift the chest wall, and the patient is often agitated. The peak flow is 40% of personal best or less than 150 L/min. Neck vein distention may result. They become bradycardic when the peak flow reaches 25% of the personal best. Admittance to the ER is required.

Bedside spirometry

This can be used to monitor obstruction during an acute asthma attack. CBC and serum electrolytes are obtained to help monitor the course of therapy. A sputum culture may be obtained to rule out infection

Wheezing

This is an unreliable sign to gauge the severity of an attack. Many patients with minor attacks wheeze loudly while patients with severe asthma attacks have no audible wheezing because of marked reduction in airflow.