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Asthma
Definition
Reactive airway disease Chronic inflammatory lung disease
Inflammation causes varying degrees of obstruction in the airways
Triggers of Asthma
Allergens Exercise Respiratory Infections Nose and Sinus problems Drugs and Food Additives GERD Emotional Stress
Fig. 28-1
Asthma
Pathophysiology
Bronchospasm Airway inflammation
Asthma
Pathophysiology
Early-Phase Response Peaks 30-60 minutes post exposure, subsides 3090 minutes later Characterized primarily by bronchospasm Increased mucous secretion, edema formation, and increased amounts of tenacious sputum Patient experiences wheezing, cough, chest tightness, and dyspnea
Asthma
Pathophysiology
Late-Phase Response Characterized primarily by inflammation Histamine and other mediators set up a selfsustaining cycle increasing airway reactivity causing hyperresponsiveness to allergens and other stimuli Increased airway resistance leads to air trapping in alveoli and hyperinflation of the lungs If airway inflammation is not treated or does not resolve, may lead to irreversible lung damage
Fig. 28-3
Asthma
Clinical Manifestations
Unpredictable and variable Recurrent episodes of wheezing, breathlessness, cough, and tight chest
Asthma
Clinical Manifestations
Expiration may be prolonged from a inspiration-expiration ratio of 1:2 to 1:3 or 1:4 Between attacks may be asymptomatic with normal or near-normal lung function
Asthma
Clinical Manifestations
Wheezing is an unreliable sign to gauge severity of attack Severe attacks can have no audible wheezing due to reduction in airflow Silent chest is ominous sign of impending respiratory failure
Asthma
Clinical Manifestations
Difficulty with air movement can create a feeling of suffocation
Patient may feel increasingly anxious Mobilizing secretions may become difficult
Asthma
Clinical Manifestations
Examination of the patient during an acute attack usually reveals signs of hypoxemia
Restlessness Increased anxiety Inappropriate behavior Increased pulse and blood pressure Pulsus paradoxus (drop in systolic BP during inspiratory cycle >10)
Asthma
Complications
Status asthmaticus Severe, life-threatening attack refractory to usual treatment where patient poses risk for respiratory failure
Asthma
Diagnostic Studies
Detailed history and physical exam Pulmonary function tests Peak flow monitoring Chest x-ray ABGs
Asthma
Diagnostic Studies
Oximetry Allergy testing Blood levels of eosinophils Sputum culture and sensitivity
Asthma
Collaborative Care
Education
Start at time of diagnosis Integrated into every step of clinical care Tailored to needs of patient Emphasis on evaluating outcome in terms of patients perceptions of improvement
Self-management
Asthma
Collaborative Care
Acute Asthma Episode
O2 therapy should be started and monitored with pulse oximetry or ABGs in severe cases Inhaled -adrenergic agonists by metered dose using a spacer or nebulizer Corticosteroids indicated if initial response is insufficient
Asthma
Collaborative Care
Acute Asthma Episode Therapy should continue until patient is breathing comfortably wheezing has disappeared pulmonary function study results are near baseline values
Asthma
Collaborative Care
Status asthmaticus
Most therapeutic measures are the same as for acute Increased frequency & dose of bronchodilators Continuous -adrenergic agonist nebulizer therapy may be given
Asthma
Collaborative Care
Status asthmaticus
IV corticosteroids Continuous monitoring Supplemental O2 to achieve values of 90% IV fluids are given due to insensible loss of fluids Mechanical ventilation is required if there is no response to treatment
Asthma
Drug Therapy
Long-term control medications
Quick-relief medications
Asthma
Drug Therapy
Bronchodilators
-adrenergic agonists (e.g., albuterol, salbutamol[Ventolin]) Acts in minutes, lasts 4 to 8 hours Short-term relief of bronchoconstriction Treatment of choice in acute exacerbations
Asthma
Drug Therapy
Bronchodilators
Useful
in preventing bronchospasm precipitated by exercise and other stimuli Overuse may cause rebound bronchospasm Too frequent use indicates poor asthma control and may mask severity
Asthma
Drug Therapy
Bronchodilators (longer acting)
12 or 24 hr; useful for nocturnal asthma Avoid contact with tongue to decrease side effects Can be used in combination therapy with inhaled corticosteroid
8
Asthma
Drug Therapy
Antiinflammatory drugs
Corticosteroids (e.g., beclomethasone, budesonide) Suppress inflammatory response Inhaled form is used in long-term control Systemic form to control exacerbations and manage persistent asthma
Asthma
Drug Therapy
Antiinflammatory drugs Corticosteroids
Do
not block immediate response to allergens, irritants, or exercise Do block late-phase response to subsequent bronchial hyperresponsiveness Inhibit release of mediators from macrophages and eosinophils
Asthma
Drug Therapy
Anti-inflammatory drugs
Mast cell stabilizers (e.g., cromolyn, nedocromil) Inhibit release of histamine Inhibit late-phase response Long-term administration can prevent and reduce bronchial hyper-reactivity Effective in exercise-induced asthma when used 10 to 20 minutes before exercise
Asthma
Drug Therapy
Leukotriene modifiers (e.g. Singulair)
Leukotriene potent bronchco-constrictors and may cause airway edema and inflammation Have broncho-dilator and anti-inflammatory effects
Asthma
Patient Teaching Related to Drug Therapy
Correct administration of drugs is a major factor in determining success in asthma management
Some persons may have difficulty using an MDI and therefore should use a spacer or nebulizer DPI (dry powder inhaler) requires less manual dexterity and coordination
Asthma
Patient Teaching Related to Drug Therapy
Inhalers should be cleaned by removing dust cap and rinsing with warm water -adrenergic agonists should be taken first if taking in conjunction with corticosteroids
Nursing Management
Nursing Diagnoses
Ineffective airway clearance Anxiety Ineffective therapeutic regimen management
Nursing Management
Planning
Normal or near-normal pulmonary function Normal activity levels No recurrent exacerbations of asthma or decreased incidence of asthma attacks Adequate knowledge to participate in and carry out management
Nursing Management
Health Promotion
dust covers Use of scarves or masks for cold air Avoid aspirin or NSAIDs
Nursing Management
Health Promotion
Prompt diagnosis and treatment of upper respiratory infections and sinusitis may prevent exacerbation
Fluid intake of 2 to 3L every day
Nursing Management
Health Promotion
Adequate nutrition Adequate sleep Take -adrenergic agonist 10 to 20 minutes prior to exercising
Nursing Management
Nursing Implementation
Acute Intervention
Monitor respiratory and cardiovascular systems Lung sounds Respiratory rate Pulse BP
Nursing Management
Nursing Implementation
ABGs
Pulse
Nursing Management
Nursing Implementation
Nursing Interventions
Administer
Nursing Management
Nursing Implementation
An important goal of nursing is to decrease the patients sense of panic
Stay with patient Encourage slow breathing using pursed lips for prolonged expiration Position comfortably
Nursing Management
Nursing Implementation
The
patient must learn about medications and develop self-management strategies and health care professional must monitor responsiveness to medication
must understand importance of continuing medication when symptoms are not present
Patient
Patient
Nursing Management
Nursing Implementation
Important patient teaching:
Seek medical attention for bronchospasm or when severe side effects occur Maintain good nutrition Exercise within limits of tolerance
Nursing Management
Nursing Implementation
Important patient teaching (cont.):
Patient must learn to measure their peak flow at least daily Asthmatics frequently do not perceive changes in their breathing
Nursing Management
Nursing Implementation
Counseling may be indicated to resolve problems Relaxation therapies may help relax respiratory muscles and decrease respiratory rate
Nursing Management
Nursing Implementation
Peak Flow Results Green zone
Nursing Management
Nursing Implementation
Peak Flow Results Yellow zone
Nursing Management
Nursing Implementation
Peak Flow Results Red zone
50% or less of personal best Indicates serious problem Definitive action must be taken with health care provider