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Adult I Asthma Notes
• Asthma is a chronic inflammatory disorder of the airways
• Leads to recurrent episodes of wheezing, breathlessness, chest tightness, and cough
o Particularly at night or early morning
• Widespread variable airflow obstruction that is usually reversible
• Unpredictable course with periods of adequate control to exacerbations with poor
control
• Risk factors and triggers Male, obese, genetics, immune responses, allergens, o
exercise, air pollutants Smoke, exhaust, occupational factors, respiratory tract o
infections, nose and sinus problems
o Drug and food additives like beta blockers and ACE inhibitors, GERD, and
psychological factors
• Triggers of asthma includes the asthma triad Nasal polyps o
o Asthma
o Sensitivity to aspirin and NSAIDs Wheezing develops in
about 2 hours
Develop sensitivity to salicylates
• Factors causing obstruction Swollen mucosa o
o Mucus
o Muscle in spasm
o We would give any combination of the following: bronchodilators, steroids,
albuterol, oxygen, chest physiotherapy, and fluids
o Arterial blood gases play a factor here
• Asthma: Clinical manifestations Characteristics including wheezing, cough, o
dyspnea, and chest tightness
May be abrupt or gradual
Lasts minutes to hours
Severity of wheeze may not be indicative of severity of attack!
Cough, night and early morning Frequency of nocturnal o
awakenings due to cough, wheezing, or dyspnea is used as an indicator for
the severity of asthma
o Cough could be the only symptom in a certain case called cough-variant asthma –
• Prolonged expiration is usually at a ratio of 1:3 or 1:4 in patients with asthma,
whereas the normal is 1:2 Bronchioles are narrow, so it takes longer for the air to o
get out of the lungs 1 for inspiration, 2 for expiration asthma o – 1 for inspiration
and 3 or 4 for expiration
o Increased anxiety because patient cannot breathe well Inability o
to complete a full sentence or take a deep breath
o Hypoxemia can result, causing restlessness, anxiety, increased BP
and pulse, and increased RR Patient will typically be in tripod o
position
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• Classification of asthma severity is in a few stages Intermittent asthma can lead to o
persistent asthma and has 3 subcategories (mild, moderate, severe)
o This is based on current impairment, so patients move to different classifications
– this is used to determine treatment
• Drug therapy Stepwise approach Make sure patients are educated so they know –o
what’s happening to them so that they can stay out of the hospital
o Patient can increase meds, add meds, but the patient should call the physician so
they can get guidance
o Beyond the stepwise approach patients go home with asthma action plan –
• How to use a peak flow meter Yellow marker = peak flow number Record o o
highest of 3 numbers on the peak flow chart Do not stick tongue inside the tip of o
the peak flow
• Complications of asthma Severe to life-threatening exacerbations o
Dyspnea at rest
Speak words, not sentences or inability to speak
Sitting forward
RR over 30
HR over 120
Peak flow 25-40% of personal best
Use of accessory muscles
Agitated to drowsy/confused
Perspiring profusely
Neck vein distention
• Positioning
o If the patient loses consciousness, it can lead to possible airway obstruction o
Reposition the airway first (pull chin, jaw thrust) and if that does not work, we
put the patient in a side-lying position
• Diagnostic studies (WILL BE ON EXAM!) History and physical o
o Spirometry usually normal between asthma attacks if the patient has no other –
underlying pulmonary diseases
Bronchodilator can be given during test to measure response o
Peak expiratory flow rate (PEFR)
o Eosinophils
o Chest x-ray if patient is asymptomatic, it will usually be normal, but it is used as –
a baseline because during an attack, it will hyperinflate
o Sputum specimen for culture and sensitivity test to rule out a bacterial infection
o Allergy skin testing
• Interprofessional care Avoid triggers of acute attacks o
o Pre-medicate before exercising (sports asthma)
o Short-term (rescue) inhaler Long-term or controller medication Asthma o o
guidelines are also helpful
o National Asthma Education and Prevention Program (NAEPP) of the National
Heart, Lung, and Blood Institute developed guidelines as well
Provides updated recommendations for selecting care and treatment
based on the individual needs of patients with asthma
• Goals of asthma treatment The current guidelines focus on: o
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Assessing the severity of the disease at diagnosis
and initial treatment
Monitoring periodically to control the disease o
Validated questionnaires exist for asthma patients
• Drug therapy IV or inhalers o
Meter-dose inhalers (MDI)
Dry powder inhalers (DPI)
• Spacers are good for children and for acute asthma attacks in order to help with
coordination
• Nursing management
o Assessment – assess patient’s ability to participate
Clinical manifestations
Precipitating or aggravating factors
Use of inhalers and other medications During acute attack: o
assess RR/HR, use of accessory muscles, lung sounds, PERF, ABGs, and pulse
ox
• Asthma Goals
o Minimal s/s during the day and night Acceptable activity levels o
o Maintenance of greater than 80% of personal best PEFR Few or no adverse o
effects of therapy No acute exacerbations of asthma o
o Adequate knowledge to participate in and carry out the plan of care
We want the patient to be able to breathe, no AEs from meds, and
understand what’s going on to treat and prevent attacks
• Health promotion Education! o
Identify and avoid known triggers
Dress properly to avoid cold air
Prompt diagnosis and treatment of URI/sinusitis
• Acute interventions Asthma action plans o
Dictates what symptoms or peak flow reading necessitates a change in
asthma care to gain control
o Patient can take 2-4 puffs of SABA every 20 minutes as a rescue plan
o Oxygen nasal cannula or mask to get PaO2 of 60 or oxygen saturation greater
than 90%, continuous pulse ox, bronchodilator treatment (SABA)
• Asthma action plan is based on symptoms and peak flow, with colors (green, yellow,
red) Normal peak flow conducted for 2 weeks when they are well (3x a day) o –
For 80% of those attempts, they should be in the green zone
• Remain on current medications
o Yellow zone 50-79% of the best peak flow, s/s getting worse, clinician will –
provide quick relief med, continue taking green zone meds but get one added
because the patient is now in the yellow zone and cannot breathe as well as they
used to (something is triggering the asthma)
o Red zone peak flow is 50% of best, s/s getting worse, clinician will write in what –
the patient will take escalation in care that patients are getting at home in an –
effort to reduce exacerbation of asthma attacks
Indicates serious problem This is to give patients as much power and o
resources to manage asthma without going to the hospital
• Once in the hospital, monitor respiratory and cardiac status
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• Monitor wheezing louder wheezing may indicate responding to therapy –
• “Silent chest” or severely diminished breath sounds can be a life-threatening
situation 100% oxygen, hourly SABA (inhaled medication), IV steroids o
• Calm, quiet, reassuring attitude, stay with patient
• Ambulatory and home care Education, monitoring, control Nutrition, exercise, o o
sleep Measure peak flow daily Asthma action plan o o
• A patient who is experiencing an acute asthma attack is admitted to the ER. Which
assessment should the nurse complete first? o Listen to the patient’s breath sounds
o o Ask about inhaled corticosteroid use Determine when the dyspnea started
o Obtain the forced expiratory volume (FEV) flow rate
• A patient is admitted to the ER with a severe exacerbation of asthma. Which finding is
of most concern to the nurse?
o Unable to speak and sweating profusely
This is the answer because this is the most unexpected outcome if they –
cannot speak, they cannot breathe PaO2 of 80 mm Hg and PaCO2 of 50 mm Hg o
o o Presence of inspiratory and expiratory wheezing Peak expiratory flow rate at
60% of personal best
• Asthma Care Plan:
o Ineffective airway clearance
Goals:
• Maintain clear airway and remove excess secretions
• Normal breath sounds and RR
Asthma Management:
• Monitor Rate, Rhythm, Depth, and Effort of respiration to
evaluate intervention and effevtiveness
• Observe chest movement and symmetry, use of accessory
muscles, and retractions to evaluate respiratory status
• Auscultate breath sounds
• Administer medication
• Coach in breathing/relaxation techniques to improve rhythm and
rate
• Offer warm fluids to liquefy secretions and promote
bronchodilation.
o Anxiety related to difficulty breathing
Goals:
• Reports decreased anxiety with increased control of respirations
• Vital signs within normal limits
Management
• Identify when level of anxiety changes to determine precipitating
factors
• Use calm reassuring approach to provide reassurance
• Stay with patient to promote safety and reduce fear
• Encourage verbalization of feelings, perceptions, and fears
• Provide factual information concerning diagnosis, treatment, and
prognosis to help know what to expect
• Instruct patient in the use of relaxation techniques to relieve
tension and to promote ease of respirations
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o Deficient knowledge related to lack of information and education about asthma
Goals
• Describe the disease process and treatment regimen
• Demonstrates correct administration of aerosol medications
• Expresses confidence in ability for long-term management of
asthma
Management
• Determine patient/family understanding of disease and
management to assess learning needs
• Teach patient to identify and avoid triggers as possible to prevent
attacks
• Encourage verbalization of feelings about diagnosis, treatment
and impact on lifestyle to offer and support and increase
compliance with treatment
• Educate patient about the use of the PEFR meter at home to
promote self-management of symptoms
• Instruct patient/family on anti-inflammatory and bronchodilator
medications and appropriate use to understand effects
• Teach proper techniques to use medication and equipment
(inhaler, nebular, PEFR meter)
• Assist in the recognition of signs/symptoms of impending
asthmatic reaction
• Establish a written pla with patient for managing exacerbations
