1. Asthma

2. Definition & key points
Asthma is a chronic inflammatory disorder of the airways.
It is an intermittent and reversible airflow obstruction that affects the bronchioles.
Obstruction may be caused by:
inflammation of airway (edema/swelling)
hyper-responsiveness (increased mucus production), or
Bronchoconstriction

4. Diagnoses; Signs & Symptoms
Four categories of Asthma:
Mild intermittent: Symptoms occur less than twice a week.
Mild persistent: Symptoms occur more than twice a week, but not daily.
Moderate persistent: Daily symptoms occur in conjunction with exacerbations twice a week.
Severe persistent: Symptoms occur continually, along with frequent exacerbations that limit the client’s physical activity and quality of life

5. Common Causes/Triggers for Asthma Attacks
Family history
Environmental factors, such as
changes in temperature and humidity
Pollutants
Smoke
Strong odors (for example, perfume)
Allergens (feathers, dust, animal dander, dust mites, molds)

6. Goals of Asthma Management
Improve airflow.
Relieve symptoms.
Prevent acute attacks.
Reducing asthma morbidity is a goal of Healthy People 2010.

7. Common Triggers for Asthma Attacks
Exercises
Stress (emotionally upset)
Medications (aspirin, NSAIDS, beta-blockers, cholinergic drugs)
Enzymes, including those in laundry detergents
Chemicals (for example, household cleaners)

8. Common Triggers for Asthma Attacks
Weather changes
Upper respiratory infections
Cold air
Rhinosinusitis
Gastroesophageal reflux

9. Diagnostic Procedures and Nursing Interventions
Pulmonary function tests are the most accurate tests
Forced vital capacity (FVC) is the volume of air exhaled from full inhalation to full exhalation.
Forced expiratory volume in the first second (FEV1) is the volume of air blown out as hard and fast as possible during the first second of the most forceful exhalation after the greatest full inhalation.
Peak expiratory rate flow (PERF) is the fastest airflow rate reached during exhalation.
A decrease in FEV1 or PERF by 15 to 20% below the expected value is common in clients with asthma.
An increase in these values by 12% following the administration of bronchodilators is diagnostic for asthma.

10. Diagnostic Procedures and Nursing Interventions
Arterial Blood Gases (ABGs)
Decreased PaO2
PaCO2 may be decreased in early stages of an attack due to the client’s increased work of breathing. It will rise as fatigue sets in.
Chest x-ray is used to diagnose changes in chest structure over time.

11. Assessment
Clients with mild to moderate asthma may experience few or no symptoms between asthma attacks.
During attacks, monitor for signs and symptoms.
Dyspnea
Chest tightness
Coughing
Wheezing
Mucus production
Use of accessory muscles
Poor oxygen saturation (low SaO2)
diaphoresis, tachycardia, and
widened pulse pressure.

12. Assess/Monitor
Client’s respiratory status (airway, RR, use of accessory muscles, oxygenation status) before and after intervention
Client’s history regarding current and previous asthma exacerbations
Onset and duration
Precipitating factors
Changes in medication regimen
Medications that relieve symptoms
Other medications taken
Self-care methods used to relieve symptoms
General appearance (chest diameter)
Laboratory findings (ABGs, sputum culture results)

13. NANDA Nursing Diagnoses
Impaired gas exchange
Ineffective airway clearance
Ineffective breathing pattern
Anxiety

14. Nursing Interventions
Administer oxygen therapy as prescribed.
Place the client in high-Fowler’s position
Monitor pulse & RR during an acute attack.
Initiate and maintain IV access.
Administer medications as prescribed:
Bronchodilators
Short-acting beta2 agonists, such as albuterol (Ventolin) provide rapid reliefs

15. Nursing Interventions
Anticholinergic drugs (Atrovent), block the parasympathetic nervous system, allowing for bronchodilation & decreased pulmonary secretions.
Methylxanthines (theophylline), require close monitoring of serum medication levels
Anti-inflammatories decrease airway inflammation.
Corticosteroids; if given systemically, monitor for serious SE
Monoclonal antibodies, such as Xolair

16. Nursing Interventions
Combination agents (bronchodilator and anti- inflammatory)
Ipratropium and albuterol (Combivent)
Fluticasone and salmeterol (Advair)
If prescribed separately for inhalation administration at the same time, administer the bronchodilator first in order to increase the absorption of the anti-inflammatory agent.
Maintain a calm and reassuring behavior.

17. Client Education
Instruct the client how to recognize and avoid triggering agents
Instruct the client how to properly self-administer medications (nebulizers and inhalers).
Educate the client regarding infection prevention techniques.
Encourage the client to get a pneumonia vaccine.
Promote good nutrition.
Reinforce importance of good hand hygiene.
If the client smokes, discuss the effects of smoking on asthma and possible smoking cessation strategies.
Encourage regular exercise as part of asthma therapy.
Promotes ventilation and perfusion.
Maintains cardiac health
Enhances skeletal muscle strength.
Clients may require pre-medication.
Provide referral to support groups as needed.

18. Complications and Nursing Implications
Respiratory Failure
Persistent hypoxemia
Monitor oxygenation levels and acid-base balance.
Prepare for intubation and mechanical ventilation as indicated.
Status Asthmaticus
Life-threatening episode of airway obstruction that is often unresponsive to common treatment.
Extreme wheezing, labored breathing, use of accessory muscles, distended neck veins, and risk for cardiac and/or respiratory arrest.

19. Status Asthmaticus Causes: Infection, anxiety, nebulizer abuse,
dehydration,
increased adrenergic blockage, and
nonspecific irritants may contribute to these episodes

20. Management of status asthmaticus
Prepare for emergency intubation.
As prescribed, administer potent systemic bronchodilators, such as epinephrine, and initiate systemic steroid therapy.
Respiratory and cardiac rhythm should be monitored continuously during
the acute phase and until the patient stabilizes and responds to therapy.
Assess the patient’s skin turgor for signs of dehydration; fluid
intake is essential to combat dehydration, to loosen secretions,
and to facilitate expectoration.
• Administer IV fluids as prescribed, up to 3 to 4 L/day, unless
contraindicated.
Encourage the patient to conserve energy.
Ensure patient’s room is quiet and free of respiratory irritants
(eg, flowers, tobacco smoke, perfumes, or odors of cleaning
agents); nonallergenic pillows should be used.