Nursing Diagnosis: Care for Individuals with Asthma

If you're a nurse, or nursing student, and want to follow a plan of care for an individual with asthma, you can take a look at some common nursing diagnosis to guide you. Today we'll summarize five and go into more depth with one of them. 

5 Nursing Diagnosis for Asthma: 

1.) Ineffective airway clearance (when one's actively experiencing an asthma attack)

2.) Ineffective breathing pattern (increased rate of breathing;may be due to fear or anxiety)

3.) Absence of knowledge related to asthma treatment (if a patient has not been educated on asthma and the medication they're prescribed) 

4.) Ineffective management of therapeutic regiment (if a patient is struggling with a medication schedule for example) 

5.) Impaired gas exchange (due to narrowing of airways not allowing adequate oxygen to enter the lungs) 

Now let's take a deeper look into the first diagnosis: Ineffective airway clearance. 

This nursing diagnosis would be an actual issue (it's not a risk for). 

Related to: inflammation in the airway and bronchospasms. 

Plan/Nursing interventions: Position patient so that they're sitting up. Assess patient's breath sounds with a stethescope, observe their breathing pattern, check their oxygen saturation. Administer medications (bronchodilators, metered dose inhalers, nebulizers, etc.). Educate patient and family on how to use medications. 

Outcome: The desired outcome would be for the patient's airway to be clear and the patient to breath easily again. 

For a guide to asthma care for nurses check out these websites that give a complete plan of action: http://www1.us.elsevierhealth.com/MERLIN/Gulanick/archive/Constructor/gulanick03.html

http://www1.us.elsevierhealth.com/SIMON/Ulrich/Constructor/diagnoses.cfm?did=130

Sources: 
EHS: Nursing Diagnosis Care Plans, 4/e - Airway Clearance, Ineffective. (n.d.). Retrieved February 27, 2015, from http://www1.us.elsevierhealth.com/MERLIN/Gulanick/archive/Constructor/gulanick03.html

EHS: Nursing Care Planning Guides - Care Planner: Diagnosis: Impaired respiratory function. (n.d.). Retrieved February 27, 2015, from http://www1.us.elsevierhealth.com/SIMON/Ulrich/Constructor/diagnoses.cfm?did=130

Nursing Care for Asthma

This post will focus on nursing care for individuals with asthma. Whether or not you're a nurse, it still may be useful in understanding what to expect from your nursing care team if you, or someone you know has asthma. 

Let's start with a summary of the the nursing care for individuals with asthma by breaking it down into assessment, therapeutic interventions and education. Here are some examples under each category.  

Assessment: Monitoring breath sounds, respiration rate and rhythm, vital signs, and presence of a cough.

Therapeutic Interventions: Medication administration, suggesting the sitting position for most effective breathing, use of a pillow when coughing, use of incentive spirometry and ambulation to maintain lung expansion and to prevent mucus buildup (in a hospital setting), and use of humidifier if indicated.  

Education: Teaching techniques for medication administration including the use of a spacer, explaining side effects and dosing regiment, teaching what environmental factors may be asthma triggers and suggestions for how to record when symptoms are worse to narrow down specific triggers to the individual. 

In addition to assessment, interventions, and education the nurse may also play an important role in communicating with respiratory therapy, or a physician.  

As we've discussed in previous blogs, the use of medication can be critical in asthma care and is a big part of nursing support for patients with asthma. Here's a table that summarizes the asthma medications: 

For a complete guide to nursing care for individuals with asthma, check out this website: https://www.nasn.org/ToolsResources/Asthma

The website acts as a toolkit with links to other sites that share research on asthma, continued education opportunities and specifics for asthma in children for not only nurses, but schools and families as well. 

Resources: 

Asthma Medications Chart - Health Insurance Quotes. (n.d.). Retrieved February 21, 2015, from http://healthtipsinsurance.com/stories/24085/Asthma-Medications-Chart.html

EHS: Nursing Diagnosis Care Plans, 4/e - Airway Clearance, Ineffective. (n.d.). Retrieved February 21, 2015, from http://www1.us.elsevierhealth.com/MERLIN/Gulanick/archive/Constructor/gulanick03.html

Asthma Online Tool Kit. (n.d.). Retrieved February 21, 2015, from https://www.nasn.org/ToolsResources/Asthma

Treating Asthma

The first step in treating asthma is to identify what triggers your asthma and work to eliminate or reduce them in your environment. This may mean limiting outdoor time during allergy season, or when a high smog index is in effect. Or having outdoor pets and setting up a air filters in your home. To get a complete guide on how to help reduce triggers, check out page 38 on this pdf. (Asthma Guidelines) and reference the table titled "How to Control Things That Make Your Asthma Worse".  If avoiding triggers doesn't help enough, your doctor may also recommend getting an allergy shot. 

Now let's talk about some of the medication options for asthma. The first line of defense is a fast acting inhaler to combat asthma attacks immediately. These are called bronchodilaters, or short-acting beta2-agonists. They dilate the bronchials, or airways, by relaxing the muscles that surround them. If you're needing to use the bronchodilators too frequently, your doctor will likely prescribe medication that you take daily to work consistently in lowering inflammation in your airways. The most common are inhaled corticosteroids that work to reduce the swelling and mucus secretion and cause airways to be less sensitive to triggers. Most people with asthma will need both bronchodilaters and inhaled corticosteroids and some medications are a combination of an inhaled corticosteroid and long acting bronchodilator. Here's a video that explains the difference between a rescue inhaler and a control inhaler: Asthma Medication: Control vs. Rescue 

Some common side effects of asthma medication include heart palpitations, a cough, or dry mouth. This chart breaks down specific side effects for each medication and when to discuss it with your doctor:Medication Side Effect Chart. A spacer is also recommended to allow more medication to be inhaled and reduce the effects an inhaler might cause in your mouth, or at the back of your throat. Here is a picture of a spacer and how it is used: 

For a more detailed explanation of asthma medications check out this awesome video: 

  

References: 

Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma - Summary Report 2007. (n.d.). Retrieved February 13, 2015, from http://www.nhlbi.nih.gov/health-pro/guidelines/current/asthma-guidelines/summary-report-2007

Asthma Facts Slideshow: Symptoms of Asthma, Causes, and Treatments. (n.d.). Retrieved February 13, 2015, from http://www.webmd.com/asthma/ss/slideshow-asthma-overview

Diseases & Conditions. (n.d.). Retrieved February 13, 2015, from http://my.clevelandclinic.org/health/diseases_conditions/hic_Asthma_An_Overview/hic_Medications_for_Treating_Asthma

Let me catch my breath....

There are four main signs and symptoms that are characteristic of asthma. They include coughing, wheezing, chest tightness and shortness of breath. Coughing with asthma often happens in the morning, or at night when lying down and while exercising. Wheezing is a hissing, or whistling sound that occurs during breathing. Chest tightness is a feeling like you can’t take a full breath, or as if someone were sitting on your chest. Lastly, shortness of breath is a feeling like you just can’t get enough air. Of course, having these signs and symptoms doesn’t mean you have asthma and you could have asthma without these signs and symptoms, or with just some, but these are the four most prevalent.

Here’s a fun video that explains symptoms in a kid friendly way:

And here’s another video that also explains symptoms and reminds us about why they may occur:

It’s difficult to find statistics on how many people with asthma experience each of these symptoms. Likely, this is because the symptoms can come and go with attacks and vary greatly between individuals with asthma. To help researchers and physicians move forward in finding correlations between triggers and the onset of symptoms, a medical doctor and researcher by the name of Sam Pejham has created an app for people to track their asthma. Gathering anonymous data about asthma symptoms, environmental factors, temperature change, etc. will hopefully help to advance the research of asthma. The app also helps the individual track his or her asthma, share the information with his or her physician and set-up handy things like alerts for taking medication. Here’s a link for this nifty app:  AsthmaMD



References:

What Are the Signs and Symptoms of Asthma? (n.d.). Retrieved February 5, 2015, from http://www.nhlbi.nih.gov/health/health-topics/topics/asthma/signs

What are the symptoms of asthma? - for Kids with Asthma. (n.d.). Retrieved February 5, 2015, from https://www.youtube.com/watch?v=znHd7da_7z4

Introduction to Asthma and Asthma Symptoms - The Children's Hospital of Philadelphia (1 of 7). (n.d.). Retrieved February 5, 2015, from https://www.youtube.com/watch?v=ye9uxrjkTck

About | AsthmaMD. (n.d.). Retrieved February 5, 2015, from http://www.asthmamd.org/about/

Diagnosing asthma

Welcome back. Today we're going to talk about how asthma is diagnosed. We've talked about signs and symptoms, pathophysiology and etiology, but still haven't answered how one knows when they have asthma, verses a different pulmonary disease. Wheezing, or shortness of breath may also be signs of emphysema, or COPD for example. So, how do we know it's asthma? Well, if you're having difficulty breathing and visit a doctor, he or she will most likely have you do a spirometer test. This measures how much air you can blow out of your lungs and how fast you can do it. The results will be lower than normal, if you're experiencing signs of asthma including inflamed airways, or muscle constriction. You may be given medication, such as an inhaler, to see if this helps improve the spiromter reading. If your spirometer test is normal, but you're still having difficulty breathing, your provider will likely order other tests to find out what is causing the difficulty in breathing.

Here's a good video that shows what a spirometer looks like and how it's used:

In addition to spirometer use, your provider will also look at your medical history noting any family history of asthma and when you experience symptoms, for example after a run, or when exposed to tobacco smoke. He or she will also do a physical exam, looking at your nose and throat and listening to your lung sounds. Crackles, or wheezing are signs of asthma and experiencing these from a trigger such as exercise, or exposure to allergens will also lead the provider to a diagnosis of asthma.

In summary, looking at the medical history, performing a physical exam and using a spirometer are the basics for how asthma is diagnosed. This video gives a more detailed look at how asthma could be diagnosed:

And this website also lays out details on asthma diagnosis:

http://www.nhlbi.nih.gov/health/health-topics/topics/asthma/diagnosis


How Is Asthma Diagnosed? (n.d.). Retrieved January 31, 2015, from http://www.nhlbi.nih.gov/health/health-topics/topics/asthma/diagnosis

Take a deep breath, sit back and relax.

Breath easy. Take a deep breath. Inhale deeply. Breath in and out. All commands we hear daily (especially if you're a yoga fan) that are meant to illicit peace and calmness. But what if you can't? What if the simple act of breathing, one we do millions of times during our lifespan, causes wheezing, chest tightness, and ultimately stress and panic? Someone with asthma, like myself, knows this feeling all too well. We want to take effortless breaths, but can't. But why? Let's take a deeper look into what's going on in the body when someone's experiencing the signs and symptoms of asthma.

As we discussed previously, asthma is characterized by inflammation and narrowing of the airways. In addition to the swelling, increased mucus is secreted that furthers the blockage of air into the lungs. This reaction is usually caused by a trigger or allergen such as pet dander, exercising, or temperature change just to name a few. 

Here's a video that gives a good visual of what's going in your lungs when you're experiencing asthma: 

At the end of the video they give an example of a form of management: a fast acting bronchodilator that helps the swelling to decrease and allows one to take that much needed deep breath. In future blogs we will go into other examples of management and medication options. 

In a publication posted in 2007 about asthma, they discuss airway remodeling. Airway remodeling is a relatively new finding involving asthma in which one's airways actually structurally change. "These structural changes can include thickening of the sub-basement membrane, subepithelial fibrosis, airway smooth muscle hypertrophy and hyperplasia, blood vessel proliferation and dilation, and mucous gland hyperplasia and hypersecretion. Regulation of the repair and remodeling process is not well established, but both the process of repair and its regulation are likely to be key events in explaining the persistent nature of the disease and limitations to a therapeutic response." The publication continues to give information on various studies that have been conducted around determining when and if this permanent change in lung function occurs and what treatment can be administered to prevent it. There was some evidence that showed treating asthma within the first two years of symptom onset can increase long term lung function, although nothing was conclusive and further studies need to be conducted. The full publication which gives details about the pathophysiology of asthma and various studies can be found at: http://www.ncbi.nlm.nih.gov/books/NBK7223/

So, no matter what we know management of asthma is important for quality of life- to breath without even thinking about it. But now there is some evidence that shows management of asthma may also improve long-term lung function and even overall health. 

National Asthma Education and Prevention Program, Third Expert Panel on the Diagnosis and Management of Asthma. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. Bethesda (MD): National Heart, Lung, and Blood Institute (US); 2007 Aug. Section 2, Definition, Pathophysiology and Pathogenesis of Asthma, and Natural History of Asthma.

What's the deal?

Although the management of asthma has greatly improved within the past 50 years, the prevalence has steadily been increasing. Between the years 2001 to 2009 the number of people diagnosed with asthma grew by 4.3 million. In fact, 1 in 12 people in the U.S. now suffer from asthma and the populations most effected are children, females, and minorities. 

The table below shows asthma prevalence, by selected demographic characteristics in the United States, averaged for the years 2008 to 2010.  



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The Center for Disease Control and Prevention gives the most recent data (from 2012) for mortality and morbidity from asthma. Morbidity refers to the rate at which asthma occurs in a group of people and is broken down into rates for adults and rates for children. For adults the number of non-institutionalized adults who currently have asthma is 18.7 million, or 8.0% of the population. The number of children who currently have asthma is 6.8 million, or 9.3%. The mortality rate refers to how many people have died from asthma and in 2011 the number of deaths were 3,345, or 1.1 out of 100,000. These numbers lead to questions of why. Why is the incidence greater in children? Why do the number of people with asthma continue to increase? Why do we not know the cause, or ways to prevent someone from getting asthma? Why is there not a cure? For a disease so common and well known, the underlying questions cannot currently be answered. But the question we can answer is: how do we manage the symptoms of asthma in a cost-effective way? 

Now, as with most things, the discussion of asthma prevalence leads to another question, the big cha-ching question: how much is this costing? If we look at the statistics for asthma related visits to the ER (1.8 million in 2010) and hospital stays with asthma as the primary diagnosis (439,000 with an average stay of 3.6 days) we can see how important education and access to management of the disease is. Not only does living with uncontrolled asthma lead to a lower quality of life (caused by trouble breathing and constant inflammation in your body), but it ultimately costs more in the long run when people are forced to make emergency visits. In the U.S. asthma cost $56 billion in 2007 due to medical costs, lost school and work days, and early deaths. In one article they found "the most cost-effective enhanced management was a mixture of education and self-management by an integrated team of healthcare and allied healthcare professionals". Another study also found that the use of medications that decrease inflammation (inhaled corticosteroids) and reduce the risk of asthma attacks and need for hospitalization is sometimes more expensive and less easy to obtain than inhalents that offer quick symptom relief (β2 agonist). People may use the quick solution and therefore not seek out further help from a health care team, leading to poorly managed asthma and increased risk for big ticket items (both financially and health wise)- such as asthma attacks, ER visits, or even death.  

So, the take away message remains: the importance of well managed asthma cannot be overlooked and is critical for quality of life and quality of bank accounts. 

                                                   


Asthma in the US. (2011, May 3). Retrieved January 17, 2015, from http://www.cdc.gov/vitalsigns/Asthma/?s_cid=vitalsigns_065

Trends in Asthma Prevalence, Health Care Use, and Mortality in the United States, 2001–2010. (2012, May 1). Retrieved January 17, 2015, from http://www.cdc.gov/nchs/data/databriefs/db94.htm#x2013;2010

Asthma. (2014, July 14). Retrieved January 17, 2015, from http://www.cdc.gov/nchs/fastats/asthma.htm

Yong, Y., & Shafie, A. (n.d.). Economic evaluation of enhanced asthma management: A systematic review. Retrieved January 17, 2015, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4282768/

Chiang, Aït-Khaled, Bissell, & Enarson. (n.d.). Management of asthma in resource-limited settings: Role of low-cost corticosteroid/β-agonist combination inhaler. Retrieved January 17, 2015, from http://www.ncbi.nlm.nih.gov/pubmed/25574908